Premera Blue Cross

• Lead and organize training for all Quality Specialists on audit processes, procedures, and tools. • Conduct complex audits and verifying quality standards for selected inquiries and make decisions whether discrepant information meets BCBSA and FEP audit requirements, state, and federal mandates. • Provide second-level support on escalated issues and audit findings. • Collaborate with team members, OCLD, and management to identify training gaps and business needs and implement actions while partnering to address these issues. • Review, evaluate, and provide feedback on trainees’ audits and learning processes. • Act as a consultant with external departments to help resolve high-impact business issues by recommending action plans related to quality assurance. • Assist the Data Reporting Analyst in collecting data and providing analyses for various issues across the department and other functional areas. • Foster a training and auditing culture that values diversity of thought, leveraging team member strengths to achieve team goals. • Assist with external audits and lead special projects. • Perform other duties as assigned.

Role Description Premera is committed to making healthcare work better, and it all starts with the Customer Service Representative. To help us continue to provide the best support for our customers, Premera is hiring additional Customer Service Representatives based out of Eastern Washington, Idaho, Oregon, Montana, Utah, Minnesota, Wisconsin, Tennessee, North Carolina, South Carolina, Georgia, Florida, Texas, and Arizona areas. As a Customer Service Representative, you play an essential role in ensuring that the customers we serve are provided with a first call resolution. The Customer Service Representative II (CSR II) provides inbound and outbound customer service support while ensuring delivery of accurate, complete, and timely information. CSR II conducts research to provide claims status, investigates routine questions, escalates all call issues as required, and thoroughly documents all member interactions. CSR II serves both Premera members and providers which includes doctors, facilities (clinics, hospitals, skilled nursing facilities, etc.), and vendors for multiple geographic locations. What you will love: - Set schedule with consistency – Monday through Friday, 8-hour shift between 5 a.m. and 8 p.m. Pacific Time. - Twelve weeks of paid virtual training (100% attendance required). - Work from home, full time (40-hour week). - Upon successful graduation of the 12-week training class, Premera will provide a one-time pre-tax allotment of $500 (minus taxes) towards home office furniture. - A comprehensive benefits package that is designed to promote health and well-being. - Healthcare benefits start day one. - Premera offers a generous PTO policy in addition to 8 paid days off a year plus two floating holidays. - Tuition assistance for both undergraduate and graduate level classes. - Opportunities for RISE recognition. - A nationally recognized workplace as one of the best companies to work for that nurtures an employee culture where everyone can thrive. What you will do: - Accountable for inbound and/or outbound phone-based customer service; provides first call and/or email resolution, de-escalate calls, as well as provides caller education, through clear and accurate exchange of information. - Follow-up, resolve and document issues in a timely manner. - Route inquiries needing further investigation to the appropriate department and conduct routine research as needed. - Follow up on pended items and route incoming paperwork to correct departments for completion. - Work with highly sensitive information while maintaining Personal Protected Information (PPI) requirements. - Performs with reliable and consistent behaviors, performance goals and metrics, and attendance. - Other duties as assigned. What you will bring: - High School Diploma or GED. (Required) - Two years of customer service experience in related fields (Required) which includes the following: - Ability to defuse conflict and address customer concerns effectively with empathy and respect. - Demonstrated recent experience with Microsoft Office Suite or equivalent software platforms, including proficiency in navigating multiple screens and systems simultaneously while providing live call support. - Demonstrated ability to accept constructive feedback, adapt work practices accordingly, and implement changes to improve performance. - Ability to adapt communication style to broad audiences. - Ability to work a variety of shifts based on quality metrics (if shift bid applies). - Two (2) years of college coursework or three (3) years of work experience in customer service. - Experience in: - Healthcare, insurance, benefits, and/or claims processing industries. - Call centers with high volume inbound/outbound calls. - Recorded screen settings. - High volume metrics and audited work. What you will gain: - Deep healthcare and insurance knowledge, and an understanding of the provider ecosystem by working with clinics, hospitals, and vendors, and understanding their needs. - Regulatory and compliance awareness, including the handling of Personal Protected Information (PPI) and HIPAA-related practices. - Daily use of ALICE, Premera’s AI-powered virtual agent, to access procedures and guidance. - Career progression pathways: CSR roles feed into many other operations roles, evidenced by nearly 70% of promotions in Operations coming from Customer Service. Physical Requirements: - This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. - This role requires the ability to keyboard, to communicate and to receive detailed information through verbal communication clearly and understandably in person, and over the telephone. Benefits - Medical, vision, and dental coverage with low employee premiums. - Voluntary benefit offerings, including pet insurance for paw parents. - Life and disability insurance. - Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service. - Wellness incentives with a wide range of mental well-being resources for you and your dependents. - Generous paid time off to reenergize. - Tuition assistance for both undergraduate and graduate degrees. - Employee recognition program to celebrate anniversaries, team accomplishments, and more. - For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement. - Commuter perks make your trip to work less impactful on the environment and your wallet. - Free convenient on-site parking. - Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable. - Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more. - Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling. - Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus. Equal Employment Opportunity/Affirmative Action Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785. The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary range for this role is posted below; we generally target up to and around the midpoint of the range. National Salary Range: $38,500.00 - $57,800.00 We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.

• Accountable for inbound and/or outbound phone-based customer service. • Provides first call and/or email resolution. • De-escalate calls and provides caller education through clear and accurate exchange of information. • Follow-up, resolve and document issues in a timely manner. • Route inquiries needing further investigation to the appropriate department. • Conduct routine research as needed.

Role Description Premera is committed to making healthcare work better, and it all starts with the Customer Service Representative. To help us continue to provide the best support for our customers, Premera is hiring additional Customer Service Representatives based out of Eastern Washington, Idaho, Oregon, Montana, Utah, Minnesota, Wisconsin, Tennessee, North Carolina, South Carolina, Georgia, Florida, Texas, and Arizona areas. If you have 12 months of customer service experience this can be your opportunity to start your career! As a Customer Service Representative, you play an essential role in ensuring that the customers we serve are provided with a first call resolution. The Customer Service Representative II (CSR II) plays an essential role in ensuring that the members and providers that Premera serve are provided with a first call resolution. Through applying Premera’s core values and competencies, the CSR II provides inbound and outbound customer service support while ensuring delivery of accurate, complete, and timely information. CSR II conducts research to provide claims status, investigates routine questions, escalates all call issues as required and thoroughly documents all member interactions. CSR II serves both Premera members and providers which includes doctors, facilities (clinics, hospitals, skilled nursing facilities, etc.), and vendors for multiple geographic locations. What you will love: - Set schedule with consistency – Monday through Friday, 8-hour shift between 5 a.m. and 8 p.m. Pacific Time. - Twelve weeks of paid virtual training (100% attendance required). - Work from home, full time (40-hour week). - Upon successful graduation of the 12-week training class, Premera will provide a one-time pre-tax allotment of $500 (minus taxes) towards home office furniture. - A comprehensive benefits package that is designed to promote health and well-being. - Healthcare benefits start day one. - Premera offers a generous PTO policy in addition to 8 paid days off a year plus two floating holidays. - Tuition assistance for both undergraduate and graduate level classes. - Opportunities for RISE recognition. - A nationally recognized workplace as one of the best companies to work for that nurtures an employee culture where everyone can thrive. What you will do: - Accountable for inbound and/or outbound phone-based customer service; provides first call and/or email resolution, de-escalate calls, as well as provides caller education, through clear and accurate exchange of information. - Follow-up, resolve and document issues in a timely manner. - Route inquiries needing further investigation to the appropriate department and conduct routine research as needed. - Follow up on pended items and route incoming paperwork to correct departments for completion. - Work with highly sensitive information while maintaining Personal Protected Information (PPI) requirements. - Performs with reliable and consistent behaviors, performance goals and metrics, and attendance. - Other duties as assigned. What you will bring: - High School Diploma or GED. (Required) - Two years of customer service experience in related fields (Required) which includes the following: - Ability to defuse conflict and address customer concerns effectively with empathy and respect. - Demonstrated recent experience with Microsoft Office Suite or equivalent software platforms, including proficiency in navigating multiple screens and systems simultaneously while providing live call support. - Demonstrated ability to accept constructive feedback, adapt work practices accordingly, and implement changes to improve performance. - Ability to adapt communication style to broad audiences. - Ability to work a variety of shifts based on quality metrics (if shift bid applies). - Two (2) years of college coursework or three (3) years of work experience in customer service. - Experience in: - Healthcare, insurance, benefits, and/or claims processing industries. - Call centers with high volume inbound/outbound calls. - Recorded screen settings. - High volume metrics and audited work. What you will gain: - Deep healthcare and insurance knowledge, and an understanding of the provider ecosystem by working with clinics, hospitals, and vendors, and understanding their needs. - Regulatory and compliance awareness, including the handling of Personal Protected Information (PPI) and HIPAA-related practices. - Daily use of ALICE, Premera’s AI-powered virtual agent, to access procedures and guidance. - Career progression pathways: CSR roles feed into many other operations roles, evidenced by nearly 70% of promotions in Operations coming from Customer Service. Physical Requirements: - This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. - This role requires the ability to keyboard, to communicate and to receive detailed information through verbal communication clearly and understandably in person, and over the telephone. Benefits - Medical, vision, and dental coverage with low employee premiums. - Voluntary benefit offerings, including pet insurance for paw parents. - Life and disability insurance. - Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service. - Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few. - Generous paid time off to reenergize. - Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees. - Employee recognition program to celebrate anniversaries, team accomplishments, and more. - For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement. - Commuter perks make your trip to work less impactful on the environment and your wallet. - Free convenient on-site parking. - Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable. - Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more. - Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling. - Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.

• Lead complex actuarial and analytical initiatives, defining scope, work plans, and execution strategies. • Advise leadership on analytical strategy, risk assessment, and project priorities. • Oversee and take accountability for technical work produced by project teams. • Develop and evaluate pricing, provider reimbursement, and benefit analyses. • Interpret complex data and trends, translating insights into clear, actionable recommendations for leadership. • Drive quality through peer review and strong documentation. • Partner cross-functionally to provide ongoing and ad hoc actuarial support. • Mentor and develop junior team members.

• Partner with leadership to understand current customer experience and adjust staffing to improve customer experience. • Create and maintain schedules for Customer Service staff to ensure optimal coverage for service level goals. • Coordinate with appropriate staff and departments to schedule training, meetings and other events into the workforce management system. • Administer staff scheduling needs and time off requests in a fair and consistent manner. • Monitor call center activity and make recommendations for immediate changes to ensure call center coverage meets customers' needs. • Monitor and record all exceptions to planned schedules to provide current analysis. • Advise Call Center Management of expected performance concerns and recommend solutions. • Create and distribute ad hoc reports as needed to analyze trends.

Role Description As a Systems Analyst III, you will analyze business functions, processes, and procedures to provide solution recommendations. Solutions will include system specifications as well as business process implications, based on business objectives, business requirements, and cost effectiveness. - Represent business needs within an Agile delivery team. - Develop and retain strong positive relationships with business stakeholders. - Act as liaison with business stakeholders, planning, conducting, and leading the analysis efforts for new system implementations as well as system upgrades and maintenance. - May lead collaborative decomposition sessions to identify high-level scope of work across business and IT areas. - Collaborate with business partners, IT partners, and delivery teams on complex business challenges to identify, refine, and document business requirements in the form of epics, features, and user stories with clear acceptance criteria. - Understand process analysis and cost versus benefit analysis; apply these skills routinely. - Use a wide range of techniques including interviews, document analysis, requirements workshops, business process analysis, use case, story mapping, and task and workflow analysis. - Develop and maintain knowledge of Premera IT systems within the aligned domain (Claims) as well as supporting business and IT domains. - Research, inform, and recommend opportunities to apply business and technology solutions to address business problems. - Demonstrate strong knowledge of data considerations for assigned domain. - Create queries to troubleshoot, develop metrics, and create ad hoc reporting as needed. - Aggregate, track, analyze, and generate reports. - Perform data analysis to assist in defining functional requirements. - Develop more complex data mapping and begin to independently create modeling and data transformation rules. - May participate in multiple testing efforts. - Build test scenarios and analyze data from tests. - Work with software developer to write test scripts. - Use data extract tools to validate test results. - May provide direction and support for UAT. - Provide input on backlog priorities and dependencies. - Identify and lead improvement opportunities through analysis and understanding of business domain and technology solutions. - Provide mentorship and direction to more junior analysts within the team. Qualifications - Bachelor’s degree in information systems or computer science or equivalent experience. - 5+ years systems analysis experience. - Experience in a software development environment with Agile development practices, including Scrum and SAFe. - Knowledge of project delivery models including Agile and waterfall. - Experience using SQL for data analysis. - Experience with healthcare or health insurance industry is a plus. - Knowledge of product development tools including Azure DevOps Services, Visual Studio, Confluence, and Product Plan. Requirements - Customer-focused, with demonstrated ability to understand and align to the strategic impact/value of the business needs. - Detailed understanding of the business strategies, needs, and processes within aligned domain; clearly explains them to the delivery team. - Demonstrates accountability and delivering results within a self-organized team environment. - Possesses strong partnership with business and IT stakeholders; provides a sustainable and high level of stakeholder experience. - Aligns to established quality expectations and incorporates functional and non-functional quality measures into requirements. - Promotes teamwork; works well as a member of a team as well as successfully facilitating collaboration within the delivery team. - Experience defining software requirements for moderately complex products/solutions. - Proven ability to analyze moderately complex data and business processes. - Demonstrated ability to dissect information and organize, translate, and cross-reference requirements effectively. - Ability to effectively and professionally communicate, both orally and in writing, to a wide range of audiences. - Ability to explain technical details to non-technical users. - Makes well-informed tactical-level decisions based upon a mixture of analysis, wisdom, experience, and judgment. - Strong problem-solving and root cause analysis skills. - Strong facilitation skills; ability to facilitate medium to large group discussions to achieve defined outcomes. - Comfortable with change or uncertainty; ability to bring clarity to ambiguous moderately complex requirements or scenarios. Benefits - Medical, vision, and dental coverage with low employee premiums. - Voluntary benefit offerings, including pet insurance for paw parents. - Life and disability insurance. - Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service. - Wellness incentives with a wide range of mental well-being resources for you and your dependents. - Generous paid time off to reenergize. - Tuition assistance for both undergraduate and graduate degrees. - Employee recognition program to celebrate anniversaries and team accomplishments. - On-campus model provides flexibility with access to on-site resources and networking opportunities. - Commuter perks to make your trip to work less impactful on the environment and your wallet. - Free convenient on-site parking. - Subsidized on-campus cafes for affordable lunchtime connections. - Engaging on-site activities such as health and wellness events. - Complementary fitness & well-being center offering both in-person and virtual workouts.

• Engage target members (those who are facing medical, mental health and/or substance utilization disorders) and build a relationship that will support open and constructive dialog on sensitive topics. • Conduct initial holistic health assessments that help build an understanding of a member’s specific situation and needs and identify any social determinants of health (SDOH) and cultural influences that may impact potential lifestyle changes. • Create a space where a case manager and member can collaborate, along with relevant caregivers and providers, to develop a member-centric case management plan that sets goals, addresses potential barriers, and leads to improved health outcomes. • Monitor, evaluate, and update the effectiveness of the member's case management plan to ensure progress toward goals is being made and that current goals remain pertinent. • Facilitate communication and coordination among the health care team to maximize delivery of appropriate care. • Provide interventions focused on removing barriers, promoting positive behavior change using motivational interviewing techniques, and stabilizing the members’ natural support systems by ensuring that caregiver needs are identified and being met. • Maintain concise, accurate, and timely documentation that meets accreditation, contractual, and legal requirements.

Role Description The Care Coordinator performs clinical appeals, prospective review (benefit advisory/prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. This work is done for all lines of business and all geographic regions. - Performs medical necessity review that includes inpatient review, concurrent review, benefit advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and contracts. - Consults with Medical Directors when care does not meet applicable criteria or medical policies. - Documents clinical information completely, accurately, and in a timely manner. - Meets or exceeds production and quality metrics. - Maintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman Care Guidelines and medical policy. - Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management). - Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria. - Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance. - Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies and projects. - Performs other duties as assigned. Qualifications - Bachelor's degree or four (4) years’ work experience. (Required) - Current State Licensure as a registered nurse. (Required) - Three (3) years of clinical experience. (Required) - Utilization Management experience. (Preferred) - Experience working in the health plan industry. (Preferred) Requirements - Hours are Monday through Friday 8am to 5pm PDT. Benefits - Medical, vision, and dental coverage with low employee premiums. - Voluntary benefit offerings, including pet insurance for paw parents. - Life and disability insurance. - Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service. - Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs. - Generous paid time off to reenergize. - Tuition assistance for both undergraduate and graduate degrees. - Employee recognition program to celebrate anniversaries, team accomplishments, and more. - For hybrid employees, on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement. - Commuter perks make your trip to work less impactful on the environment and your wallet. - Free convenient on-site parking. - Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable. - Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more. - Complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling. - Challenge someone to a game of shuffleboard or ping pong while on campus.

Role Description The Care Coordinator - Retrospective performs prospective review (benefit advisory/ prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. The incumbent partners with Medical Directors and other Premera Departments such as FEP, National Account Liaisons, Health Care Services and Claims to ensure appropriate cost-effective care by applying their clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit application and provider out of network requests. This work is done for all lines of business and all geographic regions. - Performs medical necessity review that includes inpatient review, concurrent review, benefit advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts. - Consults with Medical Directors when care does not meet applicable criteria or medical policies. - Documents clinical information completely, accurately, and in a timely manner. - Meets or exceeds production and quality metrics. - Maintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman Care Guidelines and medical policy. - Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g., case management, engagement team, and disease management). - Collaborates, educates, and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria. - Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance. - Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies and projects. Qualifications - Bachelor's degree or four (4) years’ work experience (Required) - Current State Licensure as a registered nurse (Required) - Three (3) years of clinical experience (Required) - Utilization Management experience (Preferred) - Experience working in the health plan industry (Preferred) Requirements - Play a key role in improving healthcare outcomes and ensuring the judicious use of resources. - Join a team of professionals dedicated to ensuring the highest quality of care while managing utilization effectively. - Influence critical decisions that impact patient care and organizational efficiency. - Opportunities for ongoing learning and career development in the ever-changing field of healthcare. Benefits - Medical, vision, and dental coverage with low employee premiums. - Voluntary benefit offerings, including pet insurance for paw parents. - Life and disability insurance. - Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service. - Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs. - Generous paid time off to reenergize. - Tuition assistance for both undergraduate and graduate degrees. - Employee recognition program to celebrate anniversaries, team accomplishments, and more. - Commuter perks make your trip to work less impactful on the environment and your wallet. - Free convenient on-site parking. - Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable. - Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more. - Complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling. - Challenge someone to a game of shuffleboard or ping pong while on campus.