Current Career Opportunities
Current Openings
Responsibilities:
- Collaborate across department and division lines to maintain the Plan’s health plan accreditation
- Drive meaningful HEDIS and CAHPS analysis, and aid in operationalizing quality improvement value-based care pilots, programs and learning collaboratives.
- Serve as a project facilitator working with internal stakeholders to ensure full and unencumbered accreditation and the continuous quality improvement of all value-based care initiatives.
- Work with the QI team to align the department’s efforts and annual goals with the organization’s mission, vision, and strategic planning for success.
Qualifications:
- Bachelor’s degree in business or related field required, and demonstrated ability to manage multi-faceted projects is required.
- 2 – 4 years’ experience in data analytics, preferably in healthcare or health insurance setting.
- Formal coding certification required (eg: CPC, AAPC).
- Knowledge of NCQA accreditation standards.
- HEDIS and CAHPS survey process, quality improvement methodology and healthcare experience preferred.
Responsibilities:
- Review all claims data submitted for accuracy and completeness
- Analyze claims to determine appropriate coding for processing. Determine if procedure code is payable according to particular lines of business
- Review provider pricing files to determine allowances for correct payment
- Review, investigate and resolve suspended claims relying on department procedures, using system files as necessary
- Determine the correct level of coding and/or reimbursement for claims relying on department procedures, using system files as necessary
Qualifications:
- High school diploma or equivalent is required
- Strong data entry skills required
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 required, BSN desired
- OR Licensed clinician in the State of Vermont with Master of Social Work degree (LICSW) 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.
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:
- Licensed clinician in the State of Vermont with Master of Social Work degree (LICSW) 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. CCM certification preferred and encouraged when eligible.
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 required, BSN desired
- 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. CCM certification preferred and encouraged when eligible.
Responsibilities:
- Support medication quality, safety, and trend initiatives within the Pharmacy Department.
- Ensure that all provider, member, and pharmacist consultation initiatives are established and supported according to specifications, and that clinical criteria are appropriate, and in agreement with the program’s intent.
- Serve as a clinical liaison to providers and members regarding specific Blue Cross programs, provide timely responses to their inquiries and maintain documentation of medication therapy management activities, member and provider outreach regarding outcomes.
- Work closely with other members of the pharmacy team, medical staff, customer service, integrated health (quality and case management), payment integrity, and provider relations teams for individual cases as well as health plan initiatives.
- Collaborate with members and providers to develop and achieve optimal goals of medication therapy.
Qualifications:
- Pharmacist, preferably with advanced clinical training (residency, board certification); client facing experience.
- 5+ years work experience, preferably with Health Plan experience.
- Pharmacist license in Vermont.
- Clinical knowledge with ability to understand financial impact of decisions & strategy. Knowledge of PBM clinical and operational processes & capabilities.
- Medication Therapy Management (MTM) certification (BCMTMS) or experience a plus.
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.