Arkansas Blue Cross and Blue Shield

• Assess, plan, implement, coordinate, monitor, and evaluate options and services required to meet an individual’s health needs through the use of plan benefits and community resources. • Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations. • Provides specialized education and knowledge on disease specific conditions as needed and assigned. • Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery.

• Assists in development and supervises the drug utilization and prior authorization review program. • Develops and implements pharmacy cost containment strategies tailored to the specific situations and patterns of the enterprise, specific regions, and large accounts. • Drafts pharmaceutical criteria and performs other activities in support of the enterprise prior authorization program. • Keeps up-to-date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors, leadership, and clinical department as a subject matter expert (SME). • May be responsible for conducting the second level review for medical and pharmacy benefit medication prior-authorizations, exceptions, and medical necessity reviews submitted to the plan. • May be responsible for ensuring appropriate alignment of medical policies and configuration for claims processing and utilization management. • Performs other duties as assigned. • Prepares and presents reports, data and analyses on the utilization and cost trends for enterprise lines of business, specific regions, and large accounts. • Provides leadership and advice on developing and implementing pharmacy reimbursement, claims processing policies and procedures, and pharmacy vendor selection. • Reviews and interprets coverage across assigned line(s) of business to determine what type of review is required and works with requesting providers, corporate medical directors, and other internal staff, as appropriate, in determining whether a specific case presentation meets the criteria for approval according to the specific coverage criteria. • Serves as a liaison to individual pharmacists, professional pharmacy organizations, internal committees, case management, medical management, and other providers on pharmacy issues. • Supports pharmacy initiatives for member, provider, and client satisfaction. • Uses clinical knowledge and independent critical thinking skills towards interpreting criteria, policies, and procedures to make determinations on prior approval reviews and retrospective reviews and/or pharmacy consultations within case management. • Uses knowledge of the pharmacy and/or medical benefit to communicate with, and provide recommendations to Care Management nurses, social workers, and medical directors. • Uses knowledge of the pharmacy and/or medical benefit to ensure our members receive their medications in a timely fashion, avoiding delays in treatment.

• Employs advanced analytics to gain critical insights into member behavior drivers and preferences. • Consults business leaders and internal partners to apply insights to test and drive product innovation and enhancement. • Measures program outcomes and demonstrates value, helps win and retain clients, and supports information-based strategic decision making. • Brings together multiple sources of complex data to design and develop reports that answer business questions. • Collaborates with business stakeholders across the organization to understand analytics needs and deliver plans to meet those needs.

• Analyzes and resolves issues reported by external and internal users. • Attends and/or facilitates new group implementation meetings to obtain detailed benefit information. • Collaborates with Legal to resolve compliance issues. • Coordinates Plan Document language with the Benefit team for purposes of system configuration and benefit administration. • Ensures systems configuration leadership is aware of problems and the actions taken to correct problems. • Develops and maintains Plan Documents, amendments, Summary Plan Descriptions, and Summaries of Benefits and Coverages; ensuring that all documents are signed or approved in a timely manner by the Plan Administrator through direct contact with the Plan Administrator and coordination through the regional offices. • Maintains electronic storage of Plan Documents and amendments for internal staff and Web-based storage for the clients. • Performs other duties as assigned. • Provides support to the Benefit Team and internal team. • Utilizes an internet-based Plan Document system to create the initial Plan Document template. Creates and maintains libraries for the purposes of custom-tailoring of each document with language specific to the plan administration, benefit plan design, and client practices.

• Organizes, analyzes, researches and manages complex programs, medical data and activities, which integrates multiple functional areas including case management, utilization management, disease management, health education, maternal child care management programs, and/or closure of gaps in care. • Serves as a liaison facilitating a collaborative process between multiple internal functional areas, clinical leadership, primary physicians, patients and Medical Director to assist with escalated cases that requires input from multiple areas with the enterprise, providers, facilities and vendors. • Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety. • Integrates data from multiple data sources or functional areas, ensures data accuracy and integrity, and updates data as needed to develop models to be used for decision making and initiatives. • Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts. • Serves on various committees and project teams related to policy changes, system enhancements, process improvement initiatives, etc. • Monitors and evaluates data and processes to ensure accuracy and identify changes to increase efficiency and effectiveness. • Serves as a resource to Medical Director(s) and Care Management team providing analysis, reporting and research on medical conditions, medical terminology, medications, lab work, medical records, healthcare processes, coverage policies, plan guidelines, and/or health/wellness.

• Consults with users to identify current operating procedures and to clarify project objectives. • Contributes to and supports the Enterprise strategic and operational planning process including total quality management philosophies. • 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 and delivers high-availability and performance applications. • Develops and implements processes to ensure accurate and effective workflow distribution. • Develops applications and creates deliverables aligned with processes and enterprise standards. • Enhances and applies programming analysis, design, coding, testing, debugging, implementation and documentation. • Provides technical expertise of subsystems and any other performance related systems. • Uses standard application design principles to create logical and physical application designs to promote efficiency and code reuse.

• Serve as the point of contact between IT and end users. • Responsible for incident resolution by restoring services as quickly as possible or escalation to the appropriate IT resource and incident logging and categorization. • Responsible for request fulfillment support and knowledge management, providing users with guidance and support for their IT needs. • Assists in the incorporation, installation, training, support and coordination of new and ongoing projects that involve several teams.

• 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.