Your Role The Special Investigations Unit team is responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse . The Special Investigations Investigator, Consultant will report to the SIU Manager. In this role you will represent a high level of professionalism both internally and externally. Conduct investigations in accordance w

Your Work In this role, you will Be responsible for analytic work required to convert pricing and financial goals at the line of business and region level into specific action plans at the provider level that the Network team can execute Build and update models that allow the actuarial team to quantify financial gaps and opportunities at a provider level Conduct and devel

Your Work In this role, you will Be responsible for converting pricing and financial goals at the line of business and region level into specific action plans at the provider level that the Network team can execute Create value for the Growth team General Managers by ensuring they have a voice when it comes to key network decisions and network strategy Create value for th

Your Role The Network Performance Analysis and Contracts is part of the Provider Partnerships & Network Management Division and focuses on provider network performance analysis, reporting, and consulting. The Data Analyst Health, Experienced will report to the Manager, Data Analysis. In this role you will provide analytical support through the analysis and interpretation

Your Role The Population Health Management (PHM) Governance team, under the state mandate of the California Advancing and Innovating Medi Cal (CalAIM) program, is designed to proactively assess and address the care needs of beneficiaries with tailored interventions. The Business Analyst, Consultant will report to the Sr. Manager, Governance, Population Health Management.

Your Role The Network Management and Provider Partnerships team is responsible for supporting Enterprise led mandates and managing all Business led mandates. The Program Manager, Principal will oversee the intake, review, and impact assessment for all mandates to determine what Network Management teams may be impacted. This role will ensure appropriate representation from

The Medicare team is responsible for servicing Medicare members including Med Supp). Total Duals / D SNP (Dual Special Need Plans. The Supervisor will report to the department Manager. In this role you will manage a team of front line representatives, focusing on coaching/engagement, Quality, Inventory Management and helping evolve member experience. Our leadership model

Your Role The Claims Shared Support Services team actively engages in providing and eliciting business requirements for system enhancements, by identifying a desired future state that addresses a business problem utilizing multiple analytic methods e.g. interviewing, brainstorming, chair siding/observation, problem identification, and gap analysis. The Business Systems An

Your Role The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members' care including clinical nurses and treating physicians . The Behavioral Health Registered Nurse Case Manager will report to th

Your Role The Actuarial Provider Strategies team is responsible for the financial oversight, forecasting, and development of payment models and fee schedules for Blue Shield's provider partners. The Executive Assistant, Experienced will report to the Vice President of Actuarial Provider Strategies. In this role you will be responsible for the planning and implementing of

Your Role The Enterprise Finance Consolidations and Business System team is responsible for the Company's consolidated financial statements, forecasting and reporting activities, business systems and administrative expense allocations. The team manages financial forecast and annual planning activities, provide monthly, quarterly, and annual consolidated financial reportin

Your Role The Internal Controls Advisory Services team provides objective consulting and advisory services designed to add value and assist management with establishing and maintaining an effective system of internal controls. The team helps Blue Shield of California accomplish its objectives by implementing a systematic, disciplined approach to the evaluation and improve

Your Role The Medical Care Solutions Clinical Service Intake team responsible for timely and accurate processing of Treatment Authorization Request. The Clinical Services Coordinator will report to the Supervisor of Clinical Services Intake. In this role you will be for supporting clinical staff day to day operations for Promise lines of business. Your Work In this role,

Your Role The ACA Chart Program team conducts the following functions (1) identify medical records with unreported diagnosis codes, (2) retrieve those medical charts, (3) perform medical coding to convert them into risk adjustable diagnosis codes, and (4) submit to CMS via the EDGE pathway . The Risk Adjustment, Consultant will report to the Senior Manager . In this role

Your Role The Customer Experience, Digital, and Operations Analytics team is responsible for accelerating data driven value based solutions that drive out expense, generate growth while elevating experience for members, providers and brokers. The Senior Manager of Digital and Marketing Analytics will report to the Senior Director of Customer Experience, Digital, and Opera