Excellus Health Plan Inc.

Job Description: This position is responsible for coordinating, integrating, and monitoring the utilization of behavioral health (BH) or physical health (PH) services for members, ensuring compliance with internal and external standards set by regulatory and accreditation entities. Refers appropriate cases to the Medical Director for review. Refer to and work closely with Case Management to address member needs. Participates in rotating on-call schedule, as required, to meet departmental time frames. Per department needs, may be responsible for additional hours. Essential Accountabilities: Level I Performs pre-service, concurrent and post-service clinical reviews to determine the appropriateness of services requested for the diagnosis and treatment of members' behavioral health conditions, applying established clinical review criteria, guidelines and medical policies and contractual benefits as well as State and Federal Mandates. May perform clinical review...

Job Description: Summary: The Business Assurance Testing Analyst oversees business testing and User Acceptance Testing (UAT) for projects, releases, and system changes. This role develops and manages test plans, coordinates testing with business and technical teams, tracks defects and issues, reviews results, and supports business sign-off before deployment. The position helps ensure solutions meet business needs, quality standards, and readiness expectations. Hiring Team: Brian Cocozza Kirk Juhas Essential Accountabilities: Leads business testing, User Acceptance Testing (UAT), and validation efforts from planning through completion to confirm solutions meet business requirements, quality standards, and release readiness expectations. Develops and maintains test strategies, test plans, test cases, scripts, scenarios, and supporting documentation aligned to business requirements, functional requirements, acceptance criteria, change management and system...

Job Description: Summary: The Document Solutions team focuses on the design and creation of correspondence and transactional statements using various software programs. The Publishing Systems Engineer operates in a business analyst/document-generation specialist role as part of the Document Solutions team. This role focuses on programming within the various systems utilized by our Solutions Team. Essential Primary Responsibilities/Accountabilities: Level I: Develops code; analyzes, researches, and resolves system issues for electronic publishing-related problems. Creates, maintains, and follows all documented processes and standards. Builds new and updates existing workflows and documents using xml and text data in variable data composition systems based on the requirements and functional specifications. Documents functional specifications and solutions for work to be performed. Develops or assists in the development of systems testing and implementation plans. Reviews...

Job Description: Thank you for your interest in our Customer Care team. Due to the volume of applications we receive, we review all applications in the order in which they were received. If you are chosen to move to the next step in the process, you will receive a Video Assessment from recruiting@jobalerts.excellusbcbs.com. Summary The Customer Care (CC) Advocate resolves customer inquiries via telephone, walk in, mail, fax, web chat, off-phone work, and email concerning, but not limited to, contract benefits, claim payments, and enrollment in accordance with MTM, Corporate Service strategy, NCQA, and legislative requirements. The Customer Care Advocate provides service for customers and business partners while responding in a professional, efficient, and timely manner to resolve issues and enhance member & provider satisfaction/retention. The B version of this role requires the individual to speak Spanish fluently. Essential Responsibilities/Accountabilities...

Job Description: Summary The Customer Care (CC) Advocate resolves customer inquiries via telephone, walk in, mail, fax, web chat, off-phone work, and email concerning, but not limited to, contract benefits, claim payments, and enrollment in accordance with MTM, Corporate Service strategy, NCQA, and legislative requirements. The Customer Care Advocate provides service for customers and business partners while responding in a professional, efficient, and timely manner to resolve issues and enhance member & provider satisfaction/retention. The B version of this role requires the individual to speak Spanish fluently. Essential Responsibilities/Accountabilities All Levels Provides service among the customers and business partners while responding in a professional, efficient, and timely manner to enhance member and provider satisfaction and retention. Must exercise tact, patience, and professionalism at all times in responding to internal/external customers....

Job Description: Thank you for your interest in our Customer Care team. Due to the volume of applications we receive, we review all applications in the order in which they were received. If you are chosen to move to the next step in the process, you will receive a Video Assessment from recruiting@jobalerts.excellusbcbs.com. Summary The Customer Care (CC) Advocate resolves customer inquiries via telephone, walk in, mail, fax, web chat, off-phone work, and email concerning, but not limited to, contract benefits, claim payments, and enrollment in accordance with MTM, Corporate Service strategy, NCQA, and legislative requirements. The Customer Care Advocate provides service for customers and business partners while responding in a professional, efficient, and timely manner to resolve issues and enhance member & provider satisfaction/retention. The B version of this role requires the individual to speak Spanish fluently. Essential Responsibilities/Accountabilities...

Job Description: Summary: The Business Systems Analyst is a critical role in the delivery of products for Lifetime Healthcare Companies. This position collaborates with stakeholders throughout the organization to understand business objectives and defines IT system requirements and specifications for the implementation of IT system solutions. The Business Systems Analyst will serve as the primary interface between the business and IT teams to gather, document and analyze all level of requirements with the emphasis on delivering functional and non-functional requirements to solution architects and IT teams. Business Systems Analyst, in collaboration, with their stakeholders sets scope for work items. The Business Systems Analyst position is an excellent opportunity to be a part of a cross-functional team working across the enterprise, on enterprise services. We are looking for an individual who has prior, hands-on experience as a back-end software developer, to best partner...

Job Description: The Pharmacy Outreach Coordinator provides administrative support to pharmacy programs designed to generate revenue and lower pharmacy spend for our Health Plan and out of area clients, as well as lower out-of-pocket cost and improve quality metrics for our program members. The Pharmacy Outreach Coordinator performs functions as permitted by law including outreach to providers, members and/or pharmacies focusing on therapeutic interchange strategies and other cost savings or quality improvement programs. The incumbent closely with clinical and analytic staff dedicated to these programs. Essential Accountabilities: Level I Performs administrative tasks which support pharmacy programs and projects. Perform provider, member, and pharmacy outreach related to our clinical programs. Analyze financial progress reports and prioritize tasks to meet stakeholder expectations. Serves as an outpatient medication access specialist to serve members locally and...

Job Description: Summary: The Business Systems Analyst is a critical role in the delivery of products for Lifetime Healthcare Companies. This position collaborates with stakeholders throughout the organization to understand business objectives and defines IT system requirements and specifications for the implementation of IT system solutions. The Business Systems Analyst will serve as the primary interface between the business and IT teams to gather, document and analyze all level of requirements with the emphasis on delivering functional and non-functional requirements to solution architects and IT teams. Business Systems Analyst, in collaboration, with their stakeholders sets scope for work items. Essential Accountabilities: All Levels: Collaborates with all stakeholders to elicit, analyze, specify, and gather business, stakeholder, and solution requirements. This will include assisting and/or contributing to the creation of documented requirements leveraging the...

Job Description: Summary: This position assists the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. This role supports the HARP line of business. Essential Accountabilities: Level I Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate,...

Job Description: Summary: The Customer Care Advocate (CCA) resolves customer inquiries via telephone, walk in, mail, fax, web chat, off-phone work, and email concerning, but not limited to, contract benefits, claim payments, and enrollment in accordance with LOS, Corporate Service strategy, NCQA, and legislative requirements. The Customer Care Advocate provides service for customers and business partners while responding in a professional, efficient, and timely manner to resolve issues and enhance member & provider satisfaction/retention. The B version of this role requires the individual to speak Spanish fluently. Essential Responsibilities/Accountabilities: All Levels Provides service among the customers and business partners while responding in a professional, efficient, and timely manner to enhance member and provider satisfaction and retention. Must exercise tact, patience, and professionalism at all times in responding to internal/external customers. Documents,...

Job Description: Summary: This position is responsible for and participates in a wide range of provider, patient, and employer initiatives and programs. The pharmacist supports all of our lines of business which include Medicare, Commercial, Exchange (Marketplace) and Medicaid. The focus of the UM Pharmacist is to manage the quality, appropriateness, safety and cost of medications for our members through the medical management of drugs across our pharmacy and medical benefits. Essential Accountabilities: Level I Conducts drug prior authorization, exception and medical necessity reviews. Works with requesting providers or internal staff to determine whether the submitted clinical information and patient presentation meet the criteria for approval according to the drug policy, formulary availability, and specific coverage criteria. Conducts first line appeal and grievance reviews for medical and pharmacy drugs in accordance with compliance standards. Conducts...

Job Description: Summary: The Payment Integrity DRG Coding & Clinical Validation Analyst position has an extensive background in acute facility-based clinical documentation, and/or inpatient coding and has a high level of understanding of the current MS-DRG, and APR-DRG payment systems. This position is responsible for reviewing medical records for appropriate provider documentation to support the principal diagnosis, co-morbidities, complications, secondary diagnosis, surgical procedures, POA indicators to validate coding and DRG assignment accuracy, insuring the physician documentation supports the hospital coded data. Essential Accountabilities: Level I • Analyzes and audits acute inpatient claims. Integrates medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities. Draws on advanced ICD-10 coding expertise. Clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently....

Job Description: Summary: The Software Engineer is responsible for working on projects that are currently being visualized or developed by our organization. This role will be involved with the Software Development Life Cycle methodology and framework, directing software system validation and testing methods, as well as directing software programming initiatives. This position works closely with clients and cross-functional departments to communicate project statuses and proposals. This role is specific to ETL Development: Key information - Knowledge of Programming languages: XML, JavaScript, SQL Developer Tools: Git, Azure Devops, CDIPC - Cloud Data Integration for PowerCenter ETL Process Development: Design, develop, and maintain ETL processes using Informatica PowerCenter or other relevant Informatica tools. SQL Proficiency: Utilize SQL/PLSQL to extract, transform, and load data. Exposure to advanced transformations like data transformations, Parsing JSON/XML messages...

Job Description: This position is onsite/in-person at our Court St. office in Rochester, NY. Schedule: Mon - Thurs: 10PM - 6:30AM, & Fri: 11:55PM - 8:30AM *New hires will temporarily orient on days to start. Summary: Under general supervision of department management, the Production Print Specialist may support one or more areas of Production Operations. Assignments are determined based on need; shifts may include day, evening and/or overnight hours, with some including weekend coverage. NOTE: Incumbent will be notified 3 days ahead of any shift assignment adjustment. Essential Accountabilities: All Levels Specific work activities are assigned daily based on work volumes and department needs. Observes safety and housekeeping standards in work area. Maintains appropriate files, records, and equipment manuals. Informs supervisor of equipment issues. Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies'...

Job Description: Summary: The Senior Medical Director is a strategic clinical and business leader responsible for advancing the health plan's line of business focus through value-based care, population health, medical management, quality improvement, risk adjustment, product design, and clinical transformation. This role partners closely with line of business leadership, network and provider contracting, actuarial, finance, quality, pharmacy, analytics, care management, and operations to improve clinical outcomes, member experience, provider performance, and total cost of care while ensuring compliance with CMS requirements. Essential Accountabilities: Serve a senior clinical advisor to line of business leadership on strategy, population health, medical cost, quality, and regulatory priorities, develop and execute clinical strategy in alignment with organizational growth, quality, and financial objectives. Identify clinical and market opportunities to improve member...

Job Description: Job Description Summary: Fall 2026 Internship The Fall College Internship Program is a paid co-op/internship experience that provides undergraduate and graduate students the opportunity to attend development workshops, network, and be part of our company. Our college interns work on meaningful projects, are mentored under their respective managers, and continue to develop throughout the entire fall. In addition, through the internship program, our interns can attend development workshops that are focused on key business concept. Interns may work within the skills-based tracks of Information Technology, Business Administration, Actuarial, Human Resources, Analytics & Data, Communications, Finance, Marketing & Sales, Project Management, Clinical Studies, Customer Experience, Digital Operations, and other non-technical and/or technical based degree programs. This is a paid internship/co-op. May reside in either a technical or non-technical area....

Job Description: Job Description Summary: Fall 2026 Internship The Fall College Internship Program is a paid co-op/internship experience that provides undergraduate and graduate students the opportunity to attend development workshops, network, and be part of our company. Our college interns work on meaningful projects, are mentored under their respective managers, and continue to develop throughout the entire fall. In addition, through the internship program, our interns can attend development workshops that are focused on key business concept. Interns may work within the skills-based tracks of Information Technology, Business Administration, Actuarial, Human Resources, Analytics & Data, Communications, Finance, Marketing & Sales, Project Management, Clinical Studies, Customer Experience, Digital Operations, and other non-technical and/or technical based degree programs. This is a paid internship/co-op. May reside in either a technical or non-technical area....

Job Description: Summary: This role provides the vision, strategy, functionality, and technology solutions for creating and maintaining network platforms for both public and private cloud infrastructure-based solutions. This entails the design and use of flexible platforms that deliver features, functionality, and services compatible with industry-leading providers while allowing legacy systems to interact safely when required. This position requires the necessary skills to provide technology research, evaluation, development, and delivery in support of infrastructure deployment solution lifecycles. The candidate will work directly with the Information Technology teams to lead the organization toward the deployment of technologies that may include PaaS, SaaS, hosted, and on-premises subscriptions - which will allow for flexible, secure, on-demand cloud-like functionality and services while endeavoring to provide resiliency and achieve cost reduction, while maintaining a...

Job Description: Summary: The Business Systems Analyst is a critical role in the delivery of products for Lifetime Healthcare Companies. This position collaborates with stakeholders throughout the organization to understand business objectives and defines IT system requirements and specifications for the implementation of IT system solutions. The Business Systems Analyst will serve as the primary interface between the business and IT teams to gather, document and analyze all level of requirements with the emphasis on delivering functional and non-functional requirements to solution architects and IT teams. Business Systems Analyst, in collaboration, with their stakeholders sets scope for work items. Essential Accountabilities: All Levels: Collaborates with all stakeholders to elicit, analyze, specify, and gather business, stakeholder, and solution requirements. This will include assisting and/or contributing to the creation of documented requirements leveraging the...