Responsible for establishing an infrastructure to support negotiations, implementation and oversight with all contracted vendors.
Develop metrics reporting from all vendors and have strong analytical skills to evaluate effectiveness of programs.
Serve as liaison between vendors and claims staff; audit, measure, report and evaluate all vendor’s performance.
Crum & Forster (C&F) provides specialty and standard commercial lines insurance products. They have over 2000 employees and are known for their employee-first focus and commitment to diversity, equity, and inclusion.
Responsible for planning and executing quality and oversight activities to ensure operational compliance.
Responsible for internal and external case audits for Capital and our delegated UM vendors.
Responsible for educating staff on findings, and the audit tool ensuring a consistent approach.
Capital Blue Cross promises to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
Serves as principal lead on a defined number of providers for negotiation, strategy, and market intelligence.
Assist in the establishment of contract-related criteria and contracting guidelines to optimize financial performance and minimize Plan risk.
Responsible for understanding provider partners’ service needs and incorporating contract solutions to support providers and Capital Blue Cross in reaching shared goals.
Capital Blue Cross aims to go the extra mile for their team and community. Employees consistently vote them one of the “Best Places to Work in PA” due to their supportive colleagues and focus on professional and personal growth.
Oversees the management of contractual documents that establish business relationships with vendors, customers and/or partners.
Advises management of contractual rights and obligations and provides interpretation of terms and conditions.
Manages team responsible for data entry, configuration within systems and maintenance of all changes in terms and conditions of payor contracts.
Hanger, Inc. is the world's premier provider of orthotic and prosthetic (O&P) services and products, offering the most advanced O&P solutions, clinically differentiated programs and unsurpassed customer service. Hanger's vision is to lead the orthotic and prosthetic markets by providing superior patient care, outcomes, services and value.
Partner with payer clients as a trusted clinical advisor to design drug management strategies.
Assess and benchmark PBM and other industry vendor clinical programs.
Leverage medical and pharmacy data to assess program performance.
PSG (Pharmaceutical Strategies Group), an EPIC owned company, provides consultative guidance to payer clients in the drug management market. They have over 3,000 employees nationwide and foster a 50/50 culture between producers and the rest of the business, supporting collaboration and teamwork.
Assist with entering new vendor contracts into Privia’s contract management system for review.
Draft and facilitate execution of Business Associate Agreements, Non-Disclosure Agreements, and Third Party Access Agreements.
Collaborate with Privia’s Operations Team, care centers, and vendors to support growth of care center cost savings.
Privia Health is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care in both in-person and virtual settings. The Privia Platform is led by top industry talent and exceptional physician leadership, and consists of scalable operations and end-to-end, cloud-based technology.
Maintain project documentation including presentations, plans, agendas and overall project timelines.
Act as the primary liaison between technical teams and external partners to ensure alignment on project goals.
Provide proactive communication by setting clear expectations and providing project updates before client requests.
Medrio seeks smart and capable individuals to expand product capabilities, grow their business, and better serve customers. They value collaboration, ingenuity and creating a culture of excellence, offer great benefits and promote an atmosphere of work/life balance, including flexible work schedules and locations.
Lead registration and configuration of end users and partners on DrFirst products.
Enhance customer experience and satisfaction through client surveys.
Independently manage multiple priorities, including customer setups and registrations.
DrFirst empowers providers and patients to achieve better health through intelligent medication management. They improve healthcare workflows and help patients start and stay on therapy with end-to-end solutions, serving over 420,000 prescribers, 71,000 pharmacies, and 2,000 hospitals.
Analyze and improve UM business workflows, including clinical assessments, rules, and documents.
Validate Health Services programs against business requirements and acceptance criteria.
Partner with medical directors and cross‑functional teams to review, evolve, and update InterQual and custom clinical criteria.
Wellmark is a mutual insurance company owned by its policy holders across Iowa and South Dakota, and it has built its reputation on over 80 years of trust. They are motivated by the well-being of their members and committed to sustainability and innovation.
Provide advanced analytical, reporting, and problem‑resolution support across various departments.
Partner with operational, technical, clinical, and compliance teams to analyze trends and optimize processes.
Leverage technical acumen, including FACETS and reporting tools, to drive improvements and ensure compliance.
Capital Blue Cross is committed to providing exceptional service to their team and the community. They foster a flexible work environment where health and well-being are prioritized, valuing professional and personal growth through investment in training and continuing education.
Provides analytical support to various business areas and customers.
Acts as subject matter expert providing technical and/or business knowledge to support decision-making processes.
Gathers and interprets customer requirements, competitive information, and industry standards.
Capital Blue Cross is committed to the health and well-being of its members and communities. They are considered one of the “Best Places to Work in PA” and foster a flexible environment where employees are encouraged to prioritize their health and well-being.
Tegria brings bold ideas and breakthroughs to improve care, technology, revenue, and operations in ways that move healthcare organizations from patient-centered to human-centered. At the core of their work is their talented people with different backgrounds who welcome challenge and change.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Independently manage ongoing projects, contributing to work assigned and moving the project forward through the project plan, managing client deliverables.
Prepare documents and reports to support Vendor Procurement project activity, assisting in the development of project strategies and assessing project risks.
Organize and attend stakeholder meetings, documenting action items and decisions, preparing presentation materials, and providing administrative support as needed.
EPIC Insurance Brokers & Consultants is a fast-growing firm in the insurance industry. They have over 3,000 employees nationwide and are headquartered in San Francisco. Their core values are: Owner mindset, Inspire trust, Think big, and Drive results.
Develop the provider network through contract negotiations, relationship development, industry analysis and servicing.
Analyze, review, and project financial impacts of network contract arrangements.
Implement reimbursement strategies designed to control healthcare costs.
Blue Cross of Idaho is an Idaho-based health insurance company that has been around since 1945. As a not-for-profit, they are driven to help connect Idahoans to quality and affordable healthcare while building strong networks and services with the help of customer-centric professionals.
Partner with RCM leadership to monitor performance trends and identify revenue cycle opportunities.
Support payer contracting activities, including onboarding clinical network agreements.
Act as program manager for strategic payer partnership initiatives and drive implementation.
Headspace provides access to lifelong mental health support. They combine content, clinical care, and technology to help millions of members around the world get support. Their culture is collaborative, inclusive, and grounded in their values.
Develop, implement, manage, and maintain operational systems and activities.
Serve as a liaison with all levels of the organization and outside community.
Manage multiple priorities and projects with competing deadlines.
Cleveland Clinic Health System is committed to excellence and transforming the patient experience. As a nonprofit multispecialty academic medical center with 70,800 employees worldwide, they integrate clinical and hospital care with research and education.
Manage multiple channel interactions with excellent communication skills.
Effectively present and discuss products and services to providers.
Establish and maintain positive relationships with providers.
Capital BlueCross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity employer committed to a culture of diversity and inclusion.
Leads market clinical informatics plans and data analysis.
Champions clinical projects and systems for end-user efficiency.
Identifies areas for performance improvement in clinical applications.
CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually. They have more than 157,000 employees and are committed to creating a more just and innovative healthcare delivery system.
Select, negotiate, and manage relationships with solution providers.
Develop go‑to‑market strategies and positioning for claim solutions.
Oversee profitability and financial performance of all solution lines.
Cottingham & Butler Claims Services (CBCS) sells promises to help clients through life’s toughest moments. The company aims to hire and train the best professionals in the industry, fostering a culture of continuous improvement and high expectations.