Jobs at Blue Cross NC

Manage NCQA Health Plan Accreditation focused on Member Experience and Credentialing. Lead planning, documentation, readiness reviews, surveys, gap analysis, remediation, vendor oversight, cross-functional coordination, metrics tracking, and continuous improvement to ensure accredited compliance.

Leads multiple enterprise-scale projects and initiatives from planning through implementation. Manages cross-functional teams, resources, budgets, risks, compliance, vendors, business processes, and stakeholder communications. Tracks milestones, evaluates outcomes, develops mitigation plans, and drives process improvements. Coaches team members and supports strategic business objectives through analysis, reporting, and executive communication.

Leads client relationship management and account strategy for group health and ancillary insurance products. Responsibilities include retaining and growing revenue, partnering with brokers and sales representatives, managing renewals, presenting benefit proposals, analyzing financial and utilization reports, supporting implementation and enrollment, and educating employees. The role requires strong knowledge of benefits administration, insurance products, pricing, negotiations, and client consulting.

Serve as a strategic finance leader partnering with senior leadership to drive financial strategy, multi-year planning, and operational cost optimization. Lead complex financial analyses, develop financial models and executive presentations, identify operational improvements, and oversee implementation to realize value. Influence cross-functional initiatives and provide thought leadership across divisional and enterprise planning.

Designs and develops dashboards, visualizations, reports, and analytic solutions for provider performance and D-SNP quality initiatives. Collaborates with stakeholders on prototypes, problem-solving, project delivery, and risk management. Produces care gap lists, performance projections, analytic deep dives, monitoring, and incentive-program support. May administer analytics tool servers and deploy solutions using platforms such as Tableau and Power BI.

Lead configuration and administration of the Facets packaged system, act as SME for plan/product setup and business rules, develop modification and interface requirements, validate data with SQL, support SDLC activities, liaise with business stakeholders, and mentor junior staff.

Manages end-to-end claims operations for assigned provider and customer segments, including claims processing, refunds, recoveries, accounting, financial reporting, appeals, and performance monitoring. Leads claims staff, improves workflows, ensures accuracy and compliance, resolves banking and high-value claims issues, and serves as the claims subject matter expert for ASO stakeholders. Partners with Finance, Audit, Payment Integrity, Sales, and leadership on reporting, guarantees, escalations, and operational improvements.

Designs and engineers complex physical and cloud-hosted data center infrastructures spanning network, compute, storage, platform, middleware, databases, and telephony. Responsibilities include capacity planning, technical standards, infrastructure automation, performance analysis, incident resolution, technology roadmaps, vendor collaboration, licensing, and operational readiness. Provides subject-matter expertise, leadership consultation, and guidance to less experienced engineers while supporting large-scale infrastructure projects.

Provide outreach and operational support to Medicare Advantage and ACA members to close quality and risk adjustment care gaps. Engage members and providers via calls, coach members on benefits and preventive care, maintain HIPAA-compliant documentation, support teammates, update processes, and produce reports and data tracking for leadership.

Lead a team of clinicians and coders to detect, prevent, and correct healthcare fraud, waste, and abuse. Oversee pre- and post-payment medical record reviews, ensure regulatory and contractual compliance, develop anti-fraud strategies, integrate analytics/AI tools, report performance metrics, advise on audit findings, and coordinate with providers, regulators, legal, and vendors to strengthen SIU operations.

Lead design, development, and delivery of ML, DL, and Generative AI systems for production. Apply prescriptive analytics, optimization, recommendation, and reinforcement learning. Build and evaluate models, run experiments, develop prototypes, benchmark methods, and collaborate with business partners to translate data into actionable recommendations and influence strategy.

Design and deliver complex physical and cloud data center infrastructures (network, compute, storage, telephony, middleware, database). Lead capacity planning, lifecycle management, standards, and vendor partnerships. Provide expert support during incidents, produce engineering documentation, and mentor junior engineers.

Lead an FP&A team partnering with divisional leaders to deliver budgeting, forecasting, reporting, cost analysis, and operational-to-financial integration to support strategic decision-making and resource stewardship.

Lead development and improvement of short-, medium-, and long-term cash flow forecasts. Analyze cash trends and drivers, communicate insights to senior leadership and the board, partner with finance, actuarial, investments, and treasury operations, and optimize excess cash per investment policy to support capital allocation and operational planning.

Lead accounting and reporting team to ensure accurate, timely financial reporting, manage close activities, controls, reconciliations, audits, and stakeholder reporting. Design and improve accounting policies/processes, oversee journal entries, vendor and budget management, and manage offshore vendor and external examiners.

Support actuarial teams with rating, pricing, valuation, and forecasting for health programs. Perform data retrieval/validation, experience studies, statistical analyses, ALR/UCL calculations, rate filings, and reporting. Collaborate with underwriting, network, finance, and other stakeholders and participate in the Actuarial Development Program.

Lead advanced actuarial modeling, pricing, valuation, and financial forecasting for health insurance products. Support rate development, rate filings, medical trend and experience studies, underwriting, network management, and product development. Provide consultative expertise and occasional project leadership while maintaining actuarial credentials and continuing education.

Manage pharmacy utilization management operations and clinical review teams for a business segment. Drive operational and quality targets, oversee vendors and compliance, develop strategy, represent Pharmacy in cross-functional initiatives, support budget and technology roadmaps, and provide clinical consultation on medication therapy and UM programs.

Provide strategic employment law counsel on hiring, performance management, terminations, benefits, wage-and-hour and regulatory compliance; draft policies; oversee employment litigation and EEOC matters; support corporate transactions and due diligence; select and manage outside counsel; advise senior leadership; mentor legal team and deliver training.

Lead complex actuarial projects focused on ACA risk adjustment, pricing, forecasting, and competitive benchmarking. Provide strategic actuarial guidance, manage vendor and regulator relationships, achieve financial targets, and communicate results to senior leadership while maintaining actuarial credentials.