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Results based on filters ( 37 jobs found )

Medical Review & Appeals Director (Hybrid)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications PURPOSE: We are looking for a ...
Details
Summary
About the job:
Director, Medical Review & Appeals for our Government Programs lines of business. The incumbent will ensure alignment with the overall Corporate Strategic Plan through direction and oversight of the Clinical Medical Claims Reviews, Clinical Appeals and Analysis programs and Quality of Care complaints in conjunction with Medical Policy. Ensures that delegated vendor partners are performing as required, in compliance with State and Federal regulatory requirements and accreditation agencies, to ensure members can access the...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Medical and Health Services Managers
Career Level / Education:
Bachelor's degree
Salary:
Six Figure Jobs (more than $100K)
From:
TalentAlly
Certifications / Licenses:
Certified Registered Nurse
National Committee for Quality Assurance
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Clinical Appeals Nurse (Remote)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications PURPOSE: The Clinical Appeals Nurse ...
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Summary
About the job:
completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and FEP lines of business in order to formulate a professional response to the appeal request. We are looking for an experienced clinician to work remotely from within the greater Baltimore metropolitan area. The incumbent...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Clinical Nurse Specialists
Career Level / Education:
Bachelor's degree
Salary:
Six Figure Jobs (more than $100K)
From:
TalentAlly
Certifications / Licenses:
Certified Case Manager
Legal Nurse Consultant, Certified
Certified Registered Nurse
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Clinical Appeals Manager (Hybrid)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications PURPOSE: This role manages the appeal ...
Details
Summary
About the job:
process for members and providers who appeal on behalf of members for Commercial lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State and Federal Regulatory fines and sanctions, avoid adverse exposure, reiterate the expectation of a fair and compliant appeal process for our membership, and support NCQA accreditation and the Divisional Goals for Care Management. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Compliance Managers
Career Level / Education:
Bachelor's degree
Salary:
Six Figure Jobs (more than $100K)
From:
TalentAlly
Certifications / Licenses:
National Committee for Quality Assurance
Certified Registered Nurse
Certified Case Manager
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Appeals Specialist I (Remote)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications PURPOSE: The Appeals Specialist I is ...
Details
Summary
About the job:
responsible for the initial analysis of appeals and grievance correspondence, and determination of next steps for Government Program lines of business. The incumbent is responsible for collecting, organizing and tracking information to facilitate and expedite processing of appeals and grievances received from a variety of sources. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Patient Representatives
Career Level / Education:
Postsecondary nondegree award
Salary:
Upper Middle Income Jobs ($50K-$79K)
From:
TalentAlly
Certifications / Licenses:
N/A
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Account Consultant IV - Public Sector (Remote)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications CANDIDATES MUST LIVE IN THE MD, DC, ...
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Summary
About the job:
NORTHERN VA AREA IN ORDER TO TRAVEL INTO THE OFFICES AND FOR CLIENT MEETINGS AND STAFF MEETINGS. ACTIVE HEALTH AND LIFE LICENSE IS REQUIRED. PURPOSE: This position is responsible for renewing/growing a book business which includes the most complex and jumbo accounts with indemnity and managed care medical products, ancillary/specialty products, and life products. You will be working with Public Sector accounts with various funding arrangements and plan sponsors within state, municipal and school boards ranging in girth...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Securities, Commodities, and Financial Services Sales Agents
Career Level / Education:
Bachelor's degree
Salary:
Six Figure Jobs (more than $100K)
From:
TalentAlly
Certifications / Licenses:
N/A
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Functional Analyst II (Remote)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications PURPOSE: This position will support ...
Details
Summary
About the job:
the Pricing Administration Management department with NetworX Pricing. Implements provider pricing based on contracting, standard fee schedules, mandates and any projects and or corporate initiatives related to provider pricing. Analyzes business scope of work, determines appropriate systemic process, reporting analysis, conducting training, data validation for internal/external audits, and more. ESSENTIAL FUNCTIONS: - Configures provider pricing by analyzing supporting documentation and determines appropriate...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Quality Control Analysts
Career Level / Education:
Associate's degree
Salary:
Six Figure Jobs (more than $100K)
From:
TalentAlly
Certifications / Licenses:
N/A
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Senior Domain Architect (Remote)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications PURPOSE: Your role involves managing ...
Details
Summary
About the job:
the entire lifecycle of enterprise data products and services to align with company goals. You will lead the strategic direction of data products and coordinate teams of business leaders, data engineers, data architects, data analysts, and data scientists. As a Data Product Manager, you will establish and execute the data product operating model, define the vision and strategy for data products, implement product management processes, and produce roadmaps for high-quality, high-performing data products. You will also...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Computer Systems Engineers/Architects
Career Level / Education:
Bachelor's degree
Salary:
Six Figure Jobs (more than $100K)
From:
TalentAlly
Certifications / Licenses:
N/A
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Proposal Manager (Hybrid)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications This is a hybrid role. Candidate must ...
Details
Summary
About the job:
be local to DMV offices to attend in-person meetings on a regular basis. PURPOSE: Lead the Narrative. Shape the Strategy. Win the Business. Are you a master storyteller with a strategic mindset and a passion for driving business growth? Join our dynamic team as a Proposal Manager, where your expertise will directly influence how we present our value to clientsand win their trust. As a Proposal Manager, youll be the architect behind high-impact, customer-focused proposals that showcase our solutions and set us apart in...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Industrial-Organizational Psychologists
Career Level / Education:
Master's degree
Salary:
Six Figure Jobs (more than $100K)
From:
TalentAlly
Certifications / Licenses:
Project Management Professional
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Investigator (Hybrid)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications PURPOSE: The role of the Special ...
Details
Summary
About the job:
Investigations Unit (SIU) Investigator is to assist in the reduction and recuperation of losses to CareFirst through the detection, investigation, and resolution of low to medium levels fraud, waste, and abuse schemes, resulting in the savings and recovery of funds. ESSENTIAL FUNCTIONS: - Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to medium) investigations of suspected fraud, waste, and abuse. In conjunction with assigned team or management,...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Claims Adjusters, Examiners, and Investigators
Career Level / Education:
High school diploma or equivalent
Salary:
High Income Jobs ($80K-$99K)
From:
TalentAlly
Certifications / Licenses:
Certified Fraud Examiner
ICD-10 / ICD-9
American Health Information Management Association
Certified Financial Examiner
Certified Customs Specialist
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information

Provider Relations Representative I (Hybrid)

CareFirst BlueCross BlueShield
Baltimore, MD
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Job Description Resp & Qualifications We are looking for an experienced ...
Details
Summary
About the job:
professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week. PURPOSE: This role enables a seamless provider experience serving as a primary liaison with stakeholders within Health Services and across the company. Provides communication, education, issue/dispute resolution and...
Location:
Baltimore, MD
Job Type:
Full-Time
Permanent
Occupation:
Customer Service Representatives
Career Level / Education:
High school diploma or equivalent
Salary:
Middle Income Jobs ($30K-$49K)
From:
TalentAlly
Certifications / Licenses:
N/A
Workkeys
Applied Math
N/A
Graphic Literacy
N/A
Workplace Documents
N/A
apply
Detailed Job Information
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