Current Career Opportunities
Current Openings
Responsibilities:
- Perform the primary functions of case management–assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy–as appropriate in the health plan context to help members with high health complexity overcome biological, psychological, social and/or health system barriers to improvement and to achieve their desired clinical and functional outcomes.
- Conduct comprehensive assessments and develop personalized care plans in accordance with professional case management and accreditation standards, using evidence-based tools and applying relationship-building, motivational interviewing, risk-prioritization, and other related skills.
- Work collaboratively with members, families, and providers throughout the case management process, drawing upon knowledge of clinical, regulatory, and quality standards, health plan products and benefits, and community resources.
- Support members at all stages of their health care journey and across multiple settings and specialty areas, connecting with multiple providers and community-based organizations; guide members in accessing services to support their health and wellness goals in accordance with their benefits, partnering effectively with the Plan’s customer service, providers relations, and/or utilization management teams.
- Demonstrate a commitment to integrated, multi-disciplinary practice by proactively tapping into the expertise of the Plan’s clinical team of physicians, nurses, mental health clinicians, pharmacists, and colleagues in other departments who can help ensure the best possible experience and outcomes for the member.
- Participate in department and organization-wide initiatives to enhance member health and wellness, improve the quality of care, and generate cost-savings for our customers.
Qualifications:
- Graduate of an approved program in professional nursing: RN, VT licensure and ability to apply for Compact License or active multi-state licensure required, BSN desired;
- OR Licensed Clinical Social Worker (LICSW) in the State of Vermont or comparable degree and licensure in an allied mental health profession.
- 5 years of varied clinical practice experience required, preferably in a health care setting. Experience in the following clinical areas strongly desired: inpatient and post-discharge care, management of chronic conditions, including medical and mental health conditions, and substance use disorders.
- 1-3 years of case management or similar experience desired.
- Active CCM certification preferred or initiated within 2 years of hire. Completion of CCM certification required within 3 years of hire
Responsibilities:
Create and maintain official corporate records.
- Draft the board of directors, and board committee meeting minutes for review and approval by General Counsel and Chief Executive Officer.
- Maintains files, supplies documents, and assists outside counsel in registration and continuation of federal service marks owned by the company and other matters as directed.
- Maintain and submit documentation required by the Blue Cross and Blue Shield Association.
- Prepares and maintains legal resource and research files.
- Prepares and maintains corporate policies and procedures.
- Responds to requests from staff regarding pertinent legal and corporate issues.
- As directed, communicate with attorneys, subscribers and representatives from state, local and federal agencies to answer questions and gather pertinent information.
Qualifications:
- BS in Paralegal studies, or related BS/BA with certificate in paralegal studies required.
- Three to five years of experience as a paralegal in a corporate environment required.
- One to three years of experience in health care or health insurance desired.
Responsibilities
- Perform the primary functions of outreach and enrollment for Integrated Health programs, such as:
- Triage cases to evaluate member needs following case management guidelines
- Engage in cold-call member outreach
- Screen members for medical and behavioral health needs
- Complete and enter health assessments clearly and concisely
- Work collaboratively with colleagues (internal and external), members, families, and providers throughout the case management process.
- Demonstrate a high level of professional and service excellence in all interactions, internal and external, focusing on the development of strong, collaborative relationships.
Qualifications
- Associate’s degree or equivalent experience in a related health care field preferred.
- 3-5 years’ experience in a health care setting required, including experience in a similar member- or patient-facing outreach and coordination role.
- Prior experience in a member-facing role in a health plan preferred.
- Certification or licensure in a clinical field a plus.
Responsibilities
- Oversee maintenance of medical coding changes in our Payment Integrity programs
- Research requests using multiple systems (including: Sales Force, Jira, NPS) to provide all available details to reviewer
- Use SalesForce, Jira, and NASCO claim systems, to perform functions such as initial claim review, outcome reporting, and distribution based on triage
- Correspond with providers regarding decisions about requested services and obtain medical records when necessary
- Review and respond to issues and questions from internal and external customers, both verbally and in writing
- Work collaboratively with other departments to obtain additional information to resolve inquiries
Qualifications
- Bachelor’s degree, or equivalent combination of education and experience, with a minimum of 3 years’ experience in medical coding; In-depth knowledge of CPT, ICD-9, ICD-10, HCPCS, DRG diagnosis and procedure coding
- Formal coding certification (eg: CPC, AAPC) is a must
- Experience with both professional and facility claims coding and in APC, HIPPS, or RUG coding and validation
Responsibilities:
- Oversee maintenance of medical coding changes in our Payment Integrity programs
- Research requests using multiple systems (including: Sales Force, Jira, NPS) to provide all available details to reviewer
- Use SalesForce, Jira, and NASCO claim systems, to perform functions such as initial claim review, outcome reporting, and distribution based on triage
- Correspond with providers regarding decisions about requested services and obtain medical records when necessary
- Review and respond to issues and questions from internal and external customers, both verbally and in writing
- Work collaboratively with other departments to obtain additional information to resolve inquiries
Qualifications:
- Bachelor’s degree, or equivalent combination of education and experience, with a minimum of 3 years’ experience in medical coding; In-depth knowledge of CPT, ICD-9, ICD-10, HCPCS, DRG diagnosis and procedure coding
- Formal coding certification (eg: CPC, AAPC) is a must
- Experience with both professional and facility claims coding and in APC, HIPPS, or RUG coding and validation
Responsibilities
- Prepare and review all facility, professional, and ancillary provider contracts.
- Assist in negotiation of contract terms with providers as necessary.
- Review and interpret state and federal statutes and regulations that impact the contracting process.
- Serve as the lead for payment policy development and maintenance.
- As needed, assist the General Counsel with provider-related matters including assistance with litigation discovery, research, or monitoring ongoing developments in the federal or state realm.
- Contribute to the development and maintenance of credentialing, quality, medical, and operational policies as it relates to the provider network.
- Provide accurate and timely legal support to all departments regarding provider contracting issues.
Qualifications
- J.D. from an accredited law school and member of the Vermont Bar.
- 3-5 years practicing law in a law firm or corporate legal department, or an equivalent combination of health care or insurance expertise and law firm or corporate legal department experience.
Responsibilities:
- Develop and analyze hospital and provider data to support specific negotiations and strategic network management and medical cost management initiatives.
- Develop and negotiate reimbursement proposals for the plan’s hospitals, select non-facility providers, designated agencies, and ancillary providers
- Facilitate in person or virtual meetings to develop provider partnerships and business relationships.
- Maintain communications at the executive level with hospitals and other identified providers to resolve contractual and network management issues.
- Serve as the department’s primary liaison with other internal teams to develop cost monitoring tools and review financial and utilization information.
Qualifications:
- Bachelor’s degree in health administration, finance, business, or related field, required; master’s degree preferred.
- 6 to 8 years of increasingly responsible experience in health care or insurance; or an equivalent combination of education and work experience required.
- Demonstrated experience in negotiating payer/provider contracts required.
Blue Cross and Blue Shield of Vermont strictly prohibits discrimination against or by any Blue Cross and Blue Shield employee on the basis of race, color, religion, gender, age, national origin, place of birth, sexual orientation, gender identity, ancestry, disability, pregnancy, genetic information or marital status. Blue Cross and Blue Shield will not discriminate against an employee having a positive test result from an HIV related blood test, nor will Blue Cross and Blue Shield request or require an applicant or employee to have an HIV-related test as a condition of employment. Blue Cross and Blue Shield of Vermont will not discriminate against protected veterans.