Excellus Health Plan Inc.

Job Description: Summary: This position is primarily responsible for the overall management of strategic and national accounts. This includes but is not limited to acting as a strategic advisor to support clients in the decision making process relative to benefit design, financial impacts, member experience, and industry trends. This role will focus on account retention activities and could expand to include prospecting of new business opportunities. Essential Accountabilities: Level I • Responsible for sales activities, including retention, prospecting, and cross-selling. • Establishes, develops, and maintains positive business relationships with clients, brokers, and internal department contacts. • Develops a thorough understanding of clients strategic goals, financial position and opportunities to offer solutions that meet their needs and ensure overall satisfaction. • Provides oversight for all activities that surround client solutions, operational efficiencies and...

Job Description: Summary: This position plans, directs and controls the contracting activities related to all professional (e.g., physician, dentist and non-physician including but not limited to psychologist, LCSW, podiatrist, audiologist etc.) and assigned ancillary (e.g., Homecare agency) services to assure that the Corporations act as prudent purchasers of services. This role is responsible for establishing and implementing corporate physician, non-physician and assigned ancillary contracting strategy, and developing and maintaining related contracting policies, practices, and standards across regions. Additionally, this position works with key stakeholders to ensure optimum contracting results and relations with the integrated hospital and physician entities in the region. Essential Accountabilities: • Develops and implements reimbursement and negotiation strategies for all professional and assigned ancillary service providers. Develops and maintains relationships...

Job Description: Summary: The Pharmacy Analytics Consultant provides direct support for both Pharmacy and Medical Drug information needs using a variety of analytic tools and applications. The Consultant will work with internal and external stakeholders and management, as required, to achieve Pharmacy Markets strategy, growth, compliance, and affordability objectives across the enterprise. The analyst collaborates with a multidisciplinary team (e.g., clinical, financial, sales, and Line of Business Leaders) to recommend actionable items leading to positive pharmacy financial performance. This position prepares and presents information to enable both senior management and our customers to better understand, evaluate, and support their goals. Essential Accountabilities: Level I Perform research on projects and manage and lead projects to successfully meet business objectives from across the enterprise. Analyzes data to determine business problem, trends or opportunities...

Job Description: Summary: This role will require coming into the Rochester office. The LTC Benefits Planner (Personal Care Advisor) has the responsibility of evaluating and managing those Insureds that are accessing their benefits based on their need for long-term care services. This includes ongoing evaluation of the Insured's eligibility for benefits, appropriateness of the plan of care, coordination of other insurance policies/providers, documentation and communication with Insured, Insured's family, care providers, and monitoring of claim submission and processing. All work is directed under the terms and conditions of the various individual insurance contracts. Essential Accountabilities: Level I Operates as a case advisor for Insureds accessing benefits under their LTC policy as key contact and advocate for Insured and their family. Independently manages a caseload of Insureds in accordance with time-service standards required by the Company. Evaluates...

Job Description: The Medical Director participates in the broad array of activities of the Medical Services area including, but not limited to, Medical and Pharmacy Utilization Management, quality management, member care management, and medical policy processes, and support for our various lines of business. The incumbent also provides input into the development of policies, programs and strategic objectives that cover Medical Management Services through their required participation in various committees and when assigned to other committees or workgroups as requested by leadership. They also act as a liaison with local physicians and hospitals and keep abreast of practice patterns, issues, and concerns of their regional medical community, as well as support our Provider Relations team as requested. This position is occasionally required to work evenings during high volume periods and staff shortages, e.g. cross-coverage vacations. Essential Accountabilities: Level I...

Job Description: Summary: The Purchasing Specialist manages the processes and tools for automated and stand-alone procurement systems and communicates throughout the organization as needed. Incumbent works pro-actively with supply base and supports and/or leads strategic sourcing efforts. The specialist will possess comprehensive understanding of supplier contracts terms and conditions and the ability to translate these into applicable purchasing requirements. The position will provide reporting and analytics support for Enterprise Legal & Supplier Solutions and stakeholders. Additionally, this role will support corporate programs including Contingent Labor. Essential Primary Responsibilities/Accountabilities: All Levels: Receives and processes purchase order requests to promptly secure supplier-provided products and services. Proactively reviews and serves as customer point of contact in order tracking, purchase order matching errors and is a liaison to the Accounts...

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 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 IT Cloud Engineer - Security provides the vision, strategy, functionality, and technology solutions for creating and maintaining security system and solutions for both public and private cloud infrastructure-based solutions. This position collaborates with the Information Technology teams to lead the organization toward the deployment of technologies which focus on the trust, risk, and security management of the company environment. These may include PaaS, SaaS, hosted, and on-premises solutions - allowing for flexible, secure, on-demand cloud-like functionality and services while endeavoring to provide resiliency and achieve cost reduction, while maintaining a highly secure and flexible environment. Essential Accountabilities: Level I Enforces and integrates security solutions, tools, and appropriate controls to align to security policies, standards, and procedures. Stays current with leading security technologies, standards, and best...

Job Description: Summary: The Investment Accountant will be a part of a team responsible for the accounting and financial reporting functions of the Lifetime Healthcare Companies' investments, including, but not limited to, the preparation of external (generally accepted accounting principles (GAAP) and statutory) and internal reporting, financial statement disclosures, regulatory and external audit support and is an integral member of the monthly, quarterly, and annual accounting close. This role is highly collaborative with internal Treasury, Tax, and Finance groups as well as external custodians, investment managers, consultants, and third-party service providers. This role understands relevant investment-related GAAP and statutory accounting rules and reporting to ensure the accuracy of financial data and supports ad-hoc investment-related requests. Essential Accountabilities: Level I Supports the monthly, quarterly, and annual close process for the Lifetime...

Job Description: Summary: The Actuarial Analyst performs actuarial services in support of Health Plan operations and monitors and maintains financial solvency through the understanding of current data & environment and modeling of future events. This role is amongst the group that is responsible for providing a range of experience working to establishing rates, rating structures and systems and reserves. The Actuarial Analyst has accountability to providing in depth analysis on the overall risk management and financial solvency for the health plan operation. Essential Accountabilities: Level I Establishes insurance rates, rating structures, and rating systems for groups and categories of business. Maintains reserve programs, pricing files, risk score models, benefit relativity tables and appropriate documentation for work. Develops financial projections, risk score analysis, unpaid claim liability estimates and conducts actuarial analysis for...

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 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 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 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: Summary: This role provides the vision, strategy, functionality, and technology solutions for creating and maintaining distributed 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. This position collaborates with the Information Technology teams to lead the organization toward the deployment of technologies that may include PaaS, SaaS, hosted, and on-premises solutions - 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 highly...

Job Description: Summary: This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. This position acts as a resource for both internal and external customers through completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment. Essential Accountabilities: Level I Facilitates inbound and outbound calls to customers (members and providers) by delivering excellent customer-centered service providing information regarding services in a call center environment. Responds to customers in a professional, efficient manner to encourage public acceptance of products, services, and policies. Perform triage for UM Services. Serves as the primary contact for providers regarding authorization requests. Contacts members and providers concerning regulatory...

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: Under the direction of the Assigned Management, upon successful completion of all phases of training, and in accordance with established HIPAA regulations the Enrollment Specialist performs enrollment core processing and servicing in accordance with the Health Plan Operation's enrollment regulations, Underwriting Guidelines and applicable government regulations. The focus of this role is to ensure prompt, accurate, and efficient servicing of all broker, member and group administrator inquiries for all product lines. Inquiries are received by the following but not limited to; telephone, email, written inquiries, lobby walk-in customers and through on-site visits with an employer group. The B version of this role will require the individual to be on the phone regularly. Essential Primary Responsibilities/Accountabilities: Level I: Responsible for Government Programs, Small, Mid, and Large Employer Group Subscriber Enrollment Operations. Responsible...