Blue Cross and Blue Shield of Louisiana

• Responsible for organizing, coordinating, and providing care coordination and case management services to members who are most at risk for health deterioration, sentinel events, and/or poor outcomes • Manage acute and chronically ill members to improve health and financial outcomes through analysis of needs, design, and delivery of interventions • Utilize a collaborative process to assess, plan, implement, monitor, and evaluate options and services required to meet the member’s healthcare needs • Through communication, the nurse will identify available resources to promote quality, cost effective outcomes • Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities • Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators. • The case manager will act as an advocate for the member/family, maintaining privacy, confidentiality and safety, building relationships with all relevant parties, supporting informed decision making and facilitating access to necessary and appropriate healthcare services across the continuum of care. • Implement a comprehensive case management plan • Implement specific case management activities and/or interventions and evaluate effectiveness that will lead to accomplishing the goals established in the case management plan. • Coordinate by collaborating with the member/family, providers, third party payors, employers and community resources in order to organize, integrate, and modify the resources necessary to accomplish the goals. • Interacts with patients and/or providers in order to determine patient care needs, compliance and effectiveness with planned interventions and conduct case conferences as appropriate. • Evaluates the case management plan’s effectiveness in reaching desired outcomes and goals. • Modifies any or all of the case management plan’s components if necessary. • Responsible for meeting individual quality performance standards and annual targets for program performance, such as monthly productivity and annual caseload requirements, as mutually agreed to by management team to maximize program value.

• Promote and support the BlueCross and BlueShield of Louisiana (BCBSLA) Mission Statement. • Reviews treatment procedures and services to ensure that they are within established guidelines or supported by generally accepted medical evidence when formal guidelines do not exist. • To provide direction to operations as applicable, including utilization activities. • Facilitates all physician and provider committees as needed. • Provides advice on external contractual benefit issues. • Interacts with physician and non-physician network providers on programs which may include: Performance Profiling, Disease State Management, Wellness, Medical Policy and claims related issues. • Participates in and supports internal operations such as quality assurance efforts, the BCBSLA Quality Improvement Plan, accreditation/URAC related activities and requirements, medical policy, network operations, diversity initiatives and similar initiatives.

• Deliver automated solutions for software processes • Plan, organize, coordinate, and track testing activities to ensure successful deployment of projects • Use technical skills, expertise and application knowledge to support clients, developers, and testers • Provide knowledge transfer and training to the test team as needed • Perform or participate in various types of testing and post implementation reviews as determined by the project • Help to ensure continuous improvement in Quality Assurance processes • Identify opportunities for inserting more quality within software processes • Design and execute QA tests • Run tests for databases, systems, networks, applications, hardware, and software • Identify bugs and quality issues in development, service, or business processes • Collaborate with other business units to understand the business and ensure their quality needs are being met.

• Deliver automated solutions for software processes. • Plan, organize, coordinate and track testing activities. • Support clients, developers and testers. • Provide knowledge transfer and training to the test team as needed. • Identify opportunities for inserting more quality within software processes. • Design and execute QA tests. • Run tests for databases, systems, networks, applications, hardware and software. • Identify bugs and quality issues in development, service or business processes. • Collaborate with other business units to understand quality needs.

• Deliver automated solutions for software processes • Plan, organize, coordinate and track testing activities to ensure successful project deployment • Use technical skills, expertise and application knowledge to support clients, developers and testers • Provide knowledge transfer and training to the test team • Perform or participate in various types of testing and post implementation reviews • Identify opportunities for inserting more quality within software processes • Design and execute QA tests • Run tests for databases, systems, networks, applications, hardware and software • Identify bugs and quality issues in development, service or business processes • Collaborate with other business units to understand the business and ensure their quality needs are being met • Report and document defects found during testing and work across functional teams to resolve defects

• The Senior Product Owner is a member of an agile delivery team and holds the primary responsibility for building, editing, and maintaining the team backlog consisting of user stories, defects and enablers. • Must have strong communications and leadership skills in order to serve as liaison between business stakeholders and product delivery teams. • Influence business adoption of best practices, manage dependencies and drive fidelity to future state requirements throughout the implementation process. • Work well in cross-functional, matrixed teams as well as with external vendors. • Champions agile practices within their team and coaches other team members to drive effectiveness. • Accountable for complying with all laws and regulations associated with duties and responsibilities.

Role Description The MSP Specialist is responsible for analyzing, researching and resolving CMS Section 111 MSP Response File errors to ensure data exchange compliance. Responsibilities include: - Determining Medicare order of payment and loading the appropriate Medicare COB record. - Researching and determining if 411 reporting to the MSPRC and the CMS COBC is required. - Reviewing, processing and tracking the Small Employer Exception (SEE) approvals from CMS. - Initiating procedures to recover funds from providers, subscribers or beneficiaries where overpayments have occurred. - Complying with all laws and regulations associated with duties and responsibilities. Qualifications - High School Diploma or equivalent is required. - 3 years of claims experience is required. - 1 year of COB, refund or adjustment experience is required. - Medicare experience is preferred. - Expert knowledge in primacy determination, CMS Regulations, COB Rules and Regulations is required. - Knowledge of enrollment process is preferred. - Demonstrated PC skills including Microsoft Office (e.g., Word, Excel, Outlook, etc.) and related software. - Strong verbal and communication skills with the ability to interpret and communicate information with tact, diplomacy, patience and professionalism. - Able to assist both internal and external customers in a variety of situations. - Detail-oriented and organized. - Able to shift priorities as needed to cover multiple tasks. Requirements - Researching, reviewing, and sending appropriate documentation to Medicare/CMS, the Department of the U.S. Treasury and/or collection agencies. - Meeting all CMS imposed deadlines to ensure compliance and avoid referral to the Department of Treasury. - Reviewing, processing and tracking the Small Group Exception (SEE) approvals from CMS. - Receiving or initiating an MSP 411 investigation from various sources. - Creating MSP 411 reporting letters when necessary. - Maintaining a tracking log of all MSP 411 reported situations. - Determining if Medicare mistakenly made a Primary payment. - Loading appropriate Medicare COB record to ensure accuracy of claims processing. - Reviewing the group threshold report weekly for changes. - Researching and making necessary COB adjustments on claims. - Reviewing quality audits for correction or routing within 48 hours. - Initiating procedures to recover funds from providers, subscribers, or beneficiaries. - Analyzing and correcting MSP response file errors. - Maintaining and recording number of adjustments processed and hours worked daily. Benefits - Resources to live well and be healthy. - Opportunities for continued learning and skill development. - Support for professional growth. - Engagement in serving local communities.

• Design, execute, and mature enterprise legal hold and information governance capabilities. • Support the full legal hold lifecycle, maintain partnerships with relevant departments. • Ensure defensible preservation, retention, and disposition practices across the organization.

• Design, develop, document, test, and debug software systems and applications • Service as technical expert on development projects • Participate in full development life cycle including requirements analysis and design • Support, maintain, and document software functionality • Identify and evaluate new technologies for implementation

• Identifies and assists with the implementation plan of Information Technology Service Management (ITSM). • Reviewing management information and trends to ensure services meet agreed upon service levels. • Conducts maturity assessments against the current process activities to demonstrate areas of improvement or concern. • Provides insight into the ITSM lifecycle and roadmap to define next steps of process maturity. • Accountable for complying with all laws and regulations associated with assigned duties and responsibilities.