Capital Blue Cross

• Responsible for accurately entering all group and member enrollment activity into Facets and/or eGEMS • Responds to phone and written inquiries received from Internal and External Customers • Accountable for making adjustments and corrections to group information as necessary • Educates customers on various policies and procedures related to group and member enrollment • Reviews, researches and corrects enrollment for various error reports (i.e., Group Billing Error Report, MSP Reports, etc.) • Responsible for analyzing group payments received on Facets

• Responsible for the planning, direction, coordination, execution and evaluation of educational programs supporting clinical staff and functions • Works with clinical leadership, quality, compliance and human resources to ensure the successful creation and implementation of onboarding and training programs for all clinical new hires • Develops and manages the continuing education, training, and professional development initiatives • Responsible for partnering with leadership on workflow development and maintenance for the various teams within the department • Ensures all clinical staff are in compliance with regulations and requirements through comprehensive training strategies and measuring staff understanding • Plans, organizes, evaluates, and maintains orientation/onboarding process for new clinical employees

Role Description This position is responsible for the coding and total processing of claims and triaging claim adjustments generated by our providers and subscribers or requested via Customer Service, for all lines of business. Processes claims utilizing established policies and procedures to review and correct error and warning messages. Research claims and ensures proper adjudication. - Codes and enters imaged claims and triages adjustments, submitted by members, providers and vendors. - Reviews and corrects on-line edit errors by interpreting generated warning messages. - Uses appropriate systems to research and accurately process claims. - Researches appropriate reference documents and imaged claims to make coding and payment decisions. - Reviews and processes claims that are in a pended status in accordance with processing procedures, policies and current contract specifications regarding coverage, contract limitations, and exceptions. - May identify and report possible system or Image problems to CPR or Supervisor so that corrective action may be taken. - All other duties and assignments as directed. Qualifications - Ability to communicate effectively and professionally with personnel, in both written and verbal form. - Must possess a strong attention to detail and an interest in preventing errors. - Ability to operate a personal computer (PC) and other office equipment (e.g., copy machine, fax machine, printer, calculator, etc.) as well as possess excellent keyboarding skills. - Demonstrate ability to be dependable and professional. - Demonstrate intrinsic initiative and time management skills. - Must possess a strong commitment to teamwork and an ability to foster an inclusive culture of diversity by working well and collaborating with others as needed. - Ability to accept feedback, learn, and adapt from guidance to be successful. - Ability to adapt to constant changing priorities and keeping daily responsibilities on task. - Ability to manage workload and ensure all tasks are completed within established timeframes. - Must be willing and able to work possible mandatory overtime as needed based on business needs. - Must be able to meet quality, productivity, and behavior expectations. - Must possess basic reading and arithmetic skills (reading and math comprehension). Requirements - Preferred familiarity with provider billing documents (including in/out of state hospitals, doctors, pharmacy, and suppliers) in order to code and enter appropriate data from each bill. - Preferred familiarity with medical terminology in order to correctly code and enter the appropriate ICD-10CM diagnosis code, procedure code, ancillary code, type of service, and qualifier code. - Preferred knowledge of both manual and automated aspects of claims processing and Image systems. - Preferred knowledge of claims payment policies and benefits. - Preferred competency in the use of computer applications, databases, and end user computing tools and programs, including proficiency in various software like Microsoft Windows, Email, Internet browsers, Instant Messenger, and Office (Word, Excel, etc.). Experience - Preferred FACETS claims Coding. - Preferred Facets claims processing. - Preferred WorkDesk Imaging. - Preferred Facets Customer Service Application. Education and Certifications - Must have a high school diploma or GED. Benefits - Comprehensive benefits package including Medical, Dental & Vision coverage. - Retirement Plan. - Generous time off including Paid Time Off, Holidays, and Volunteer time off. - Incentive Plan. - Tuition Reimbursement.

• Manage the assignment, workflow, and oversight process to ensure quality, consistency, and timeliness of deliverables from data engineers • Create and maintain standards for data design, modeling, and deployment in Snowflake • Provide direction and training to data engineers regarding foundational applications used in the development lifecycle • Assess new data ingestion patterns to improve efficiency and timeliness of data availability • Define data delivery strategy and monitor data release schedule • Provide guidance to data analyst community on best practices for leveraging and querying new data assets • Interpret business needs from requests, and rapidly implement effective technical solutions that meet long term objective of providing consistent data delivery across enterprise • Create and maintain ETL Source to Target mapping documents, data playbooks, and data flow inventory documents

• Manage multiple channel interactions professionally, efficiently and with excellent communication skills • Effectively present and discuss the products and services to external and internal providers • Focus on provider retention through first call resolution of concerns • Establish and maintain positive relationships with providers on behalf of the company • Complete ongoing training to stay abreast of products, services, and policy changes

• Provides physician insight and collaborates in the development and evolution of Capital’s BH program and strategy. • Participates in and advises Capital committees (e.g., Quality Improvement Committees, Utilization Management Committees, Member Safety Committee) on BH topics and strategy development. • Provides oversight, guidance, consultation and expertise to Capital’s BH clinical operations, including utilization management, care management, complex case reviews and clinical rounds. • May provide limited cross-coverage support for Care Management and Utilization Management activities, including consultation on complex cases, clinical rounds, or care coordination initiatives, as business needs require. • Reviews data to identify trends relating to BH clinical operations and provides feedback on medical necessity criteria and/or medical policies underlying BH utilization management decisions and subsequent appeals. • Collaborates cross-departmentally (internally) and with key external stakeholders, including Capital’s network providers, to drive Triple Aim outcomes. • Provides BH expertise to inform clinical programs and services that drive quality and HEDIS, STAR, and CAHPS improvement. • Works directly with Capital network providers and internally within Capital to champion provider practice transformation in support of Capital’s value-based delivery models. • Establishes relationships and regular touchpoints with key BH network providers to collaborate on opportunities to improve health outcomes for Capital’s members. • Provides clinical leadership to the development and evolution of strategies to improve access and availability of BH care and services to Capital members, including physical and BH integration models (collaborative care models) and integrated care management programs among others. • Provides clinical leadership to the development and executes on the strategic direction for Capital’s BH strategy, including any vendor-supported programs and services. • Helps to promote Capital’s clinical vision and programs in the local medical community and within Capital’s 21-county service area. • Reviews and analyzes data to drive that transformation in improving member health, experience of care, and medical costs. • Supports organizational accreditation efforts and regulatory review processes, including participation in key committees and quality improvement activities. • Performs activities in compliance with all applicable regulatory entities including NCQA, CMS, PID, and DOH, among others. • Performs other related duties and assignments as requested and directed.

• Records daily/monthly Miscellaneous Invoices for Capital Blue Cross and Subsidiaries within Workday • Verifies the accuracy of the General Ledger coding provided prior to creating the invoice • Generates and distributes invoices, weekly aging reports and statements to internal and external personnel • Responsible for the daily tracking and recording of Alternate Payee Affidavits into an Access Database • Communicates verbally or in writing with Capital's banks as needed in regard to bank statements, bank adjustments, forgery affidavits and other related documents

Role Description This position is responsible for supporting the overall success of the Government Programs (GP) Division; supporting the implementation of new products and benefit enhancements of existing products. Also responsible for assisting in the development of new operational workflows and improving existing processes. Supports Business Owners and leadership of GP with implementation cycles, updating/tracking annual timelines. Provides oversight of operational support systems in order to meet GP performance goals, ensure compliance accuracy, and ensure products meet requirements/expectations of external (regulators, providers, members, vendors) and internal customers. - Oversight of implementation activities from CMS and state application and regulatory filings through product launch and the entire product life cycle. - Ongoing management of the GP product portfolio. - Resolution of operational issues associated with product and account set up. - Ensuring products are functioning properly within existing systems (FACETS, PBM, Sales systems, etc.). - Implementing guidance changes and coordinating internal process communications. - Work on project teams with individuals with diverse levels of knowledge from throughout the organization. - Partner with GP Management and Sales, Marketing, Stars, Clinical, Pharmacy, Actuarial, Legal, Compliance, Operational Departments and other subject matter experts. Qualifications - Deep understanding of MA products and benefits. - Minimum three to five years of experience in health insurance organization managing benefits, pricing, and the operational systems that support them. - Prior experience in compliance, operations, or project management experience is preferred. - Prefer bachelor’s degree in business, health management, marketing, or communication or equivalent work experience. - Knowledge and understanding of Medicare benefits required. Requirements - Proven successful experience leading complex projects, preferably in Government Programs products. - Effective communication, both written and oral, skills and strong skills with common PC software applications (i.e. Microsoft Office) required. - Excellent analytical, organizational and project management skills required. - Ability to build successful collaborative business relationships and partner with large cross-functional teams on new product implementations and changes. - Excellent presentation skills required including presentation development, product training, process improvements, and developing policies & procedures. - Experience using effective problem solving and decision making techniques to develop recommendations and present to management/stakeholders. - Strong attention to detail and high level of accuracy. Benefits - Comprehensive benefits package including Medical, Dental & Vision coverage. - Retirement Plan. - Generous time off including Paid Time Off, Holidays, and Volunteer time off. - Incentive Plan. - Tuition Reimbursement. Physical Demands - Frequently required to sit, use hands and fingers, talk, hear, and see. - Must be able to work over 40 hours per week. - Occasionally lift and/or move up to 5 pounds. Company Description We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital, you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Role Description The Health Navigator collaborates with members, family, healthcare providers, community resources, and other members of the healthcare team to coordinate services and address barriers including access to health care, health literacy, transportation, wellness, and gaps in care. The Health Navigator will guide members to achieve optimal and vibrant health by providing tools, information, and assistance to help understand their healthcare options, take control of their healthcare needs, bridge the current gap between social-economic and medical and behavioral needs, and navigate the otherwise often confusing steps along the path to efficient and effective care. - Identifying, facilitating, and securing access to needed healthcare, social services benefits, and community resources. - Assist members with navigating the steps along the path to efficient and effective care. - Coordinate appointments with and transportation to physicians and non-physician providers to ensure timely and efficient delivery of diagnostic and treatment services when needed. - Actively monitors incoming calls, conducts outgoing calls, and responds to voice mail requests in a timely manner. - Identify and assess members’ medical, behavioral, social, emotional, and financial needs. - Effectively and efficiently utilize available resources to connect at-risk members with appropriate community resources. - Conduct health education. - Build relationships with members, their families, and caregivers to support health care goals. - Provide emotional support and/or refer to community-based or physician/provider for greater level of psychosocial intervention. - Complete education to assigned members and engage them into programs. - Complete surveys and assessments for assigned members to support health & wellness needs. - Deliver education on condition-specific topics, medication adherence, preventive care guidance, and navigation of available health benefits. - Collaborate with interdisciplinary teams to support whole-person care and improve quality outcomes. - Identify and report quality of care issues in accordance with established policies and procedures. - Document all care navigator activities in the care management documentation system. - Assist with assigned population processes including retrieving and assigning referrals. Qualifications - Critical thinking and problem-solving skills; ability to handle critical situations. - Excellent written, oral communication, listening, and organizational skills. - Ability to operate a personal computer (PC), including proficiency in Microsoft Office Products. - Able to demonstrate strong customer service skills, including tact and diplomacy. - Ability to appropriately prioritize workload and assignments. - Ability to work autonomously and as part of an interdisciplinary team. - Demonstrates sound judgment that affirms the rights and responsibilities of members, families, healthcare professionals, and organizations. Requirements - Knowledgeable on how to navigate all aspects of medical, behavioral, and social systems. - Knowledge of NCQA standards for Population Health Management, DMAA standards for disease management, and CMSA Standards of Practice for Case Management. - Knowledge of current and emerging medical treatment modalities and best practice guidelines. - Knowledge of adult learning principles, motivational interviewing, and intrinsic coaching techniques. - At least three (3) years’ recent/related experience working in health and wellness promotion, inpatient, or other appropriate clinical settings. - Behavioral Health experience beneficial but not required. Education and Certifications - Patient Navigation certification preferred or obtained within 1-year of employment. - Licensed Practical Nurse active license or degree in healthcare related field and 3 years of experience directly related to the duties and responsibilities specified. Benefits - Comprehensive benefits package including Medical, Dental & Vision coverage. - Retirement Plan. - Generous time off including Paid Time Off, Holidays, and Volunteer time off. - Incentive Plan. - Tuition Reimbursement.

• Perform contract administration activities including the preparation of contract settlements • Ensure claims are paid in accordance with contract provisions and plan payment levels • Perform research, analytic, and reporting work in support of Provider Contracting and Value Based Programs • Work with team manager and other analysts to develop and administer contracts with healthcare providers • Prepare provider contract settlements ensuring accuracy and compliance with payment provisions • Manage Cost Rate Adjustment (CRA) process • Respond to inquiries and resolve reimbursement issues from providers • Develop proactive analytical studies on provider billing patterns