Arkansas Blue Cross and Blue Shield

• Compiles reporting related to the performance and continuous improvement of Utilization Management (UM), Care Management (CM) and vendor programs. • Collaborates across clinical, operational and analytic teams for all lines of business to ensure compliant and high quality member centered outcomes. • Supports program monitoring, reporting, vendor performance management, and execution of internal operational improvements and vendor oversight for compliance requirements.

• Communicates in a clear and concise manner (whether orally or in writing) using business English and Spanish, correct grammar, and precise vocabulary; learns to make complex insurance topics accessible to a wide audience and explain benefits without resorting to jargon; develops the ability to listen, comprehend what is being said, and ask appropriate questions that help lead to issue resolution; and keeps accurate and complete electronic notes of conversations in the appropriate software systems. • Interacts directly with customers, which may include members, groups, and providers to resolve issues related to the products and services and health insurance plans offered by ABCBS and its family of companies; and completes interactions based on company standards and directives as well as within state and federal guidelines such as the privacy rules enumerated in HIPAA guidelines. • Always conducts him/herself in a positive and professional manner, addressing others with politeness, etiquette, and tact; handles confrontational situations with empathy but also in such a manner as to reach fact-based objective conclusions and resolve; and gains conclusive agreement through negotiation. • Becomes an expert on benefits and eligibility for health insurance plans supported by multiple lines of business, as requested; and knows where and how to find information pertinent to providing superior customer service.

• Analyzes financial, statistical and mathematical data to perform actuarial calculations. • Assists in the determination of pricing, reserves and/or cash flow projections, especially to determine rate accuracy. • Assists with the Division's Annual Statement exhibits. • Communicates financial, statistical, and mathematical data results to stakeholders clearly and accurately. • Demonstrates ability to meet deadlines while providing management adequate time to review the work product. • Maintains good standing as a participant in the Actuarial Development Program. • Prepares and distributes established reports for decision-makers throughout the Enterprise, responding to inquiries as needed. • Prioritizes work projects according to Enterprise needs with moderate input from management. • Provides analytic support for Enterprise and/or Divisional projects, Enterprise Risk Management, and other requests. • Retrieves and validates data for rate filings, actuarial models, and other requests as assigned. • Updates rating model factors, algorithms and studies to reflect current experience and/or changing conditions.

• Assisting with all Medicare Advantage (MA) compliance activities. • Managing operations of Compliance, including components of administration, interpretation, and enforcement of the Compliance Program. • Managing regulatory affairs, prevention, detection, and correction functions of Compliance. • Continually analyzing business needs, identify potential problems, ensure effective lines of communicating business and compliance issues, and assist in remediation. • Develops and maintains strong working relationships, collaborating and consulting with business and regulatory partners. • Develops and oversees a system for uniform response, enforcement and corrective action on matters relating to MA compliance. • Ensures that employees are trained on ABCBS’ commitment to compliance with all applicable federal and state laws and regulations.

• Consults with users to identify current operating procedures and to clarify project objectives. • Contributes to and supports the Enterprise business solutions strategic and operational planning process. • Designs, testable code and develops test protocols or plans and reviews revisions and results. • Designs and develops high-volume, low-latency applications for mission-critical systems. • Develops and implements processes to ensure accurate and effective workflow distribution. • Develops applications as defined in requirements and creates deliverables. • Provides technical expertise of subsystems and any other performance related systems.

• The CSR ensures final resolution of each customer inquiry in a timely and courteous manner while documenting detailed information relevant to the contact. • Resolution may require system research and/or contacting experts in other areas of the company. • Communicates in a clear and concise manner using business English, correct grammar, and precise vocabulary. • Interacts directly with customers to resolve issues related to products and services.

• The Licensed Masters Social Work Case Manager will work in the Clinical Services and Population Health area. • The LMSW Case Manager is responsible for providing support activities for members. • This includes significant coordination with all departments as well as providers and community based organizations to promote effective, efficient care.

• Claims processing involves the actions required to pay or deny pended claims (those which did not auto-adjudicate), including: entering data into the system; reviewing and interpreting contract benefits; conducting edit and audit resolution; determining benefit eligibility; Identifying and researching processing issues through systems and manuals; routing claims to other areas; consulting internal staff and medical providers; generating correspondence; and completing forms to obtain necessary information. • Knowledge/Continuous Learning: In order to perform the actions required of the Claim Specialist job, the incumbent must undergo initial training, on-the-job training, and continuing education. Demonstrating knowledge of and possessing the ability to access all relevant computer systems and screens in order to process claims accurately; staying current with continually changing processing procedures, benefits, and system modifications; being knowledgeable of and able to meet corporate and national (MTM) standards while maintaining acceptable performance levels based on established departmental standards for productivity and quality; and showing familiarity with corporate and professional manuals and guidebooks, including the company processing manual and ICD, CPT, and HCPS codebooks. • Other duties: As assigned.

• Analyzes and evaluates user requests for server and technical operations, services, and support. • Assists in the developing comprehensive policy and procedure documents for the open systems server infrastructure. • Assists other department teams with IT server management functions including configuration, operations, installation, maintenance, and performance tuning of all server hardware and software. • Monitors daily performance of systems and informs management of the status of the systems relative to previously established performance guidelines. • Performs technical duties assigned, as a member of department team(s) to enhance function and availability of the open system server environment. • Possesses knowledge of the strategic planning process in order to effectively maintain successful server management processes consistent with goals and objectives. • Researches and implements server components including software, hardware, security, administration, policies, and procedures. • Updates reporting mechanisms based on progression of projects.

• Serves as a liaison with contracted vendors that provide administrative and clinical services for the pharmacy program. • Responsible for the development and implementation of new benefit plans, products, and strategies. • Represents Government Programs within the enterprise regarding various issues. • Ensures execution against requirements of the Medicare Pharmacy Program as defined by CMS.