Blue Cross & Blue Shield of Rhode Island

Pay Range: $73,600.00 - $110,400.00 Please email HR_Talent_AcquisitionTeam@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process. At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer. What you will do: - Manage members through evidence-based care, promoting access to the healthcare system, and assessing needs to identify appropriate interventions and support services as well as reduce barriers to evidence-based care. Member management includes, but is not limited to, conducting health assessments (telephonic and face-to-face) to identify high-risk or emerging risk members for education and intervention; evaluating and modifying action plans by working with members and collaborating with providers. - Evaluate member services to ensure appropriate levels and coordination of care, including pre-authorization, concurrent review, quality-of-care screening, and discharge planning. Ensure member and provider satisfaction by demonstrating knowledge of member plan benefits and community resources. - Identify opportunities to moderate claims costs for employer group and individual members. Promote and monitor use of wraparound service programs for optimal member experience while managing chronic and acute care needs. - Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans for improving members’ total health. Provide continuity and consistency of care by building positive relationships between members, families, providers, care coordinators, social support partners, and the health plan. - Engage in team operations including supervision, team huddles, staff meetings, case rounds, metric management, training opportunities, department initiatives, and projects. Work collaboratively to develop and implement solutions, identify barriers, and exemplify corporate values through accountability, collaboration, integrity, and respect. - Perform other duties as assigned What you’ll need to succeed: - Unrestricted Rhode Island Nursing License - Unrestricted Massachusetts Nursing License - Three years’ experience in a medical/clinical environment or managed health plan - Must obtain Certified Case Manager (CCM) certification within three years of employment The extras: - Bachelor’s degree in nursing - Certified Case Manager (CCM) - Reside in Rhode Island or other Nurse Licensure Compact state (NLC) - Bilingual Spanish, Portuguese - Experience working in a managed care/health maintenance organization - Experience implementing and upholding Quality, CMS, NCQA requirements - Knowledge of utilization management and/or coordination of care - Knowledge of population health and chronic condition management principles, aligning with corporate initiatives such as specialty within high-risk maternity and rising risk conditions such as diabetes, hypertension, COPD, etc. - Understanding of health care delivery system access points and services - Demonstration of successful (member) engagement via application of Motivational Interviewing techniques and health coaching - Ability to navigate the healthcare delivery system - Understanding of evidence-based care programs and approaches - Strategic and critical thinking skills - Strong analytical skills - Strong business acumen - Strong presentation negotiation, problem-solving, and decision-making skills - Strong written and verbal communication skills - Ability to work effectively with a wide variety of people in individual and group settings - Strong organizing skills, with the ability to prioritize and respond to shifting deadlines - Strong time management skills Location: BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role: - In-office: onsite 5 days per week - Hybrid: onsite 2-4 days per week - Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer. The law requires an employer to post notices describing the Federal laws. Please visit  www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Manage members through the healthcare delivery system; assess needs in order to identify appropriate interventions. Conduct telephonic or face-to-face health assessments to identify high-risk or emerging risk members who would benefit from education and intervention. Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the members’ total health. - Identify opportunities to impact claims expense trends for all lines of business/or at the individual member level. - Evaluate action plans by working with members and collaborating with providers. Modify action plans as necessary. - Monitor and evaluate patient services to ensure appropriate coordination of care. - Collaborate with the Utilization Review process including pre-authorization, concurrent review, screening cases for quality of care issues, and discharge planning. - Promote member and provider satisfaction by demonstrating working knowledge of member benefits, including but not limited to health, disability, Employee Assistance or other plans/benefits available to the member. - Provide continuity and consistency of care by building positive relationships between the member and family, physicians, provider, care coordinator, and health care plan. - Work collaboratively with the team and others necessary to develop and implement solutions. - Identify barriers to performing job duties as well as opportunities for improvements. - Exemplify the corporate values in action through accountability, collaboration, integrity, and respect in maintaining a high-performance culture. - Participate in department initiatives and projects. - Perform other duties as assigned. Qualifications - A combination of education and related work experience. - Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC). - Three to five years’ experience in a medical/clinical environment or managed health plan. - Expertise working with D-SNP beneficiaries. - Must obtain Certified Case Manager (CCM) certification within three years of employment. Requirements - Professional nursing certification. - Experience working in a managed care/health maintenance organization. - Bilingual preferred. - Knowledge of utilization management and/or coordination of care. - Knowledge of population health and chronic condition management principles. - Understanding of health care delivery system access points and services. - Ability to navigate the healthcare delivery system. - Good business acumen. - Knowledge of business process improvement techniques and strategies. - Excellent verbal, written communications, and technical skills. - Negotiation skills. - Presentation skills. - Decision-making skills. - Good problem-solving skills. - Ability to interface with employees at all levels. - Ability to effectively navigate ambiguous situations with limited direction. - Excellent organizational skills and ability to successfully prioritize multiple tasks. - Ability to handle multiple priorities/projects. - Strong time management skills. Benefits - Flexible work arrangements that include remote and hybrid opportunities. - Paid time off. - Tuition reimbursement and assistance with student-loan repayment. - Health, dental, and vision insurance. - Programs that support mental health and well-being. - Competitive pay, bonuses, and investment plans. - Additional paid time to volunteer in the community. Company Description At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Our culture is one of belonging, striving to be transparent and accountable, and equipping our associates with the knowledge and resources they need to be successful.

Pay Range: $160,000.00 - $266,500.00 Please email HR_Talent_AcquisitionTeam@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process. At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer. Why this job matters: Bridge operational activities and financial processes, to enable accurate forecasting, financial reporting, and strategic decision-making. Partner closely with finance, contracting, and other business areas to ensure provider agreements and alternative payment models drive financial stability and support strategic and financial goals and mission. Lead actuarial support for risk adjustment and pharmacy rebate activities. What you will do: - Lead actuarial support for provider contracting, including feasibility analysis of proposed alternative payment models and contract structures. - Model financial impacts to inform contract negotiations, network shifts, and proposed changes. - Forecast and monitor shared savings/losses, settlement outcomes, and downstream impacts of contracting decisions. - Support risk adjustment projections and financial modeling across submission cycles to inform revenue forecasting and planning. - Analyze and forecast quality incentive payments and rebate revenue based on utilization trends and contract terms. - Collaborate with finance to ensure actuarial outputs are integrated into financial planning models and ledger entries. - Identify and explain variance drivers from new membership and provider performance throughout the year. - Serve as a translation layer between operational functions, business areas, and finance, strengthening financial forecasting and alignment. - Perform other duties as assigned. What you need to succeed: - Bachelor’s degree in Mathematics, Statistics, Economics or related field; or a combination of education and related work experience - ASA or FSA designation from the Society of Actuaries - Seven to ten years actuarial experience within the health insurance or related industry - Prior experience pricing and evaluating alternative funding arrangements in healthcare. - Medicare Advantage background - Proven track record of partnering with finance and contracting functions to drive business results. - Strong analytical, communication, and collaboration skills. - Ability to present and translate complex data into digestible information. The extras: - Experience with provider contracting, risk adjustment, and financial modeling preferred. Location: BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role: - In-office: onsite 5 days per week - Hybrid: onsite 2-4 days per week - Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer. The law requires an employer to post notices describing the Federal laws. Please visit  www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description This role involves bridging operational activities and financial processes to enable accurate forecasting, financial reporting, and strategic decision-making. - Lead actuarial support for provider contracting, including feasibility analysis of proposed alternative payment models and contract structures. - Model financial impacts to inform contract negotiations, network shifts, and proposed changes. - Forecast and monitor shared savings/losses, settlement outcomes, and downstream impacts of contracting decisions. - Support risk adjustment projections and financial modeling across submission cycles to inform revenue forecasting and planning. - Analyze and forecast quality incentive payments and rebate revenue based on utilization trends and contract terms. - Collaborate with finance to ensure actuarial outputs are integrated into financial planning models and ledger entries. - Identify and explain variance drivers from new membership and provider performance throughout the year. - Serve as a translation layer between operational functions, business areas, and finance, strengthening financial forecasting and alignment. - Perform other duties as assigned. Qualifications - Bachelor’s degree in Mathematics, Statistics, Economics or related field; or a combination of education and related work experience - ASA or FSA designation from the Society of Actuaries - Seven to ten years actuarial experience within the health insurance or related industry - Prior experience pricing and evaluating alternative funding arrangements in healthcare - Medicare Advantage background - Proven track record of partnering with finance and contracting functions to drive business results - Strong analytical, communication, and collaboration skills - Ability to present and translate complex data into digestible information Requirements - Experience with provider contracting, risk adjustment, and financial modeling preferred Benefits - Flexible work arrangements including remote and hybrid opportunities - Paid time off - Tuition reimbursement and assistance with student-loan repayment - Health, dental, and vision insurance - Programs that support mental health and well-being - Competitive pay, bonuses, and investment plans - Additional paid time to volunteer in the community Company Description At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. - Our culture is one of belonging, striving for transparency and accountability. - We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. - We’re dedicated to serving Rhode Islanders through community engagement and volunteer work.

Pay Range: $160,000.00 - $266,500.00 Please email HR_Talent_AcquisitionTeam@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process. At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer. Why this job matters: Bridge operational activities and financial processes, to enable accurate forecasting, financial reporting, and strategic decision-making. Partner closely with finance, contracting, and other business areas to ensure provider agreements and alternative payment models drive financial stability and support strategic and financial goals and mission. Lead actuarial support for risk adjustment and pharmacy rebate activities. What you will do: Lead actuarial support for provider contracting, including feasibility analysis of proposed alternative payment models and contract structures. Model financial impacts to inform contract negotiations, network shifts, and proposed changes. Forecast and monitor shared savings/losses, settlement outcomes, and downstream impacts of contracting decisions. Support risk adjustment projections and financial modeling across submission cycles to inform revenue forecasting and planning. Analyze and forecast quality incentive payments and rebate revenue based on utilization trends and contract terms. Collaborate with finance to ensure actuarial outputs are integrated into financial planning models and ledger entries. Identify and explain variance drivers from new membership and provider performance throughout the year. Serve as a translation layer between operational functions, business areas, and finance, strengthening financial forecasting and alignment. Perform other duties as assigned. What you need to succeed: Bachelor’s degree in Mathematics, Statistics, Economics or related field; or a combination of education and related work experience ASA or FSA designation from the Society of Actuaries Seven to ten years actuarial experience within the health insurance or related industry Prior experience pricing and evaluating alternative funding arrangements in healthcare. Medicare Advantage background Proven track record of partnering with finance and contracting functions to drive business results. Strong analytical, communication, and collaboration skills. Ability to present and translate complex data into digestible information. The extras: Experience with provider contracting, risk adjustment, and financial modeling preferred. Location: BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role: In-office : onsite 5 days per week Hybrid: onsite 2-4 days per week Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer. The law requires an employer to post notices describing the Federal laws. Please visit www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.