Capital Blue Cross

Partner with leadership to develop HR strategies, manage employee relations, and support organizational effectiveness. | Requires 7+ years of HR experience, strong knowledge of employment law, and experience in HR generalist or business partner roles. | Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” As a Human Resources Business Partner Sr (HRBP Sr), you will play a critical role in aligning HR strategies with business objectives. You will work closely with management and employees to foster a positive work environment, drive organizational effectiveness, and support the company’s growth and development. Your responsibilities will include strategic HR planning, talent management, employee relations and retention, management coaching, performance management, and change management. Responsibilities and Qualifications Strategic HR Planning: Develop and maintain influential relationships with leadership to drive talent outcomes that support business objectives. Assess organizational performance systemically, defining talent gaps and proposing HR solutions that support client business objectives. Provide proactive HR support, meeting regularly with business unit leaders, and managing all aspects of the employee lifecycle. Partner with business leaders and Finance on regular workforce planning data management. Ensure effective partnerships with HR Centers of Excellence (CoEs) to solve problems and execute key deliverables, driving a “one HR” experience for internal clients. Analyze data trends and metrics to inform business decisions. Partner with compensation team regarding job leveling and compensation changes, managing expectations with the business from a pay equity and budget standpoint. Work closely with HR COE members to provide business feedback and identify areas of improvement. Employee Relations: Serve as a resource and advise on general policy application and process/practice implementation. Coach managers on effective leadership skills and proactively identify team morale and engagement issues. Participate in onboarding and offboarding efforts for assigned client area. Conduct stay interviews and exit interviews to identify trends and issues, work with the HR COEs to identify and implement solutions, and provide feedback to managers, as appropriate. Support regular employee engagement survey by communicating results and partnering with managers to follow-through on measurable action plans. Responsible for resolving employees’ questions either directly or indirectly. Ensure regulatory compliance with legal requirements pertinent to the day-to-day management of employees; collaborate with the legal department when necessary. Talent Management: Facilitate annual talent and succession planning events and support annual calibration activities. Identify the talent gaps and development needs of the client group, its managers, key individuals, and people in key positions and work with the Learning and Belonging COE to identify solutions. Coach business leaders on HR policies and processes, including talent planning, learning and development, and performance management to promote engagement and a culture of continuous growth and development Performance Management: Partner with business leaders and HR COEs to identify people related issues, trends, and challenges before they arise. Assess root causes of business and organizational performance and recommend actions through consultative approach. Diagnose large scale organization effectiveness and team performance issues and partners with senior leaders and their leadership teams to implement solutions to resolve. Improve manager and employee performance by identifying and clarifying issues, evaluating potential solutions, implementing selected solutions, and coaching and counseling managers and employees. Provide performance management guidance to line management for coaching, counseling, career development, and disciplinary actions. Work with managers to address performance issues timely and efficiently. Skills: Well-developed verbal and written communications skills. Demonstrated skills in negotiation, consultative approach and networking skills. Demonstrates analytical, organization and problem solving skills in order to accurately and efficiently identify, analyze and respond to customer inquiries, as well as identify and analyze trends and discrepancies. Demonstrates ability to work independently, be flexible and react appropriately to changing job assignments and work environments. Knowledge: Proven knowledge of employment law, including regulatory compliance, terminations and EEOC claims, is necessary. Previous experience exerting strong influence on key constituents while acting as a trusted advisor and coach. Experience: 7+ years of experience in generalist, employee relations or business partner role. Breadth of experience in multiple HR disciplines, such as talent development, change management, organizational design. Education and Certifications: Bachelor’s degree in Human Resources, Business Administration, or related field. Human Resources related certification preferred. Location: This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays. Physical Demands: While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds. About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Lead enterprise IT transformation from project-centric to product-centric models, ensuring value realization and cultural change. | Extensive experience in IT strategy, portfolio management, and large-scale Agile transformations, with strong leadership and negotiation skills. | Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” This is a senior executive role responsible for leading the enterprise transition from a traditional project-centric delivery model to a modern, product-centric operating model. This role is pivotal in executing the IT&D modernization strategy, ensuring that technology investments deliver measurable business value and operational efficiency.-This leader will establish governance, portfolio management, and value realization frameworks that enable disciplined execution of the modernization roadmap. Acting as the enterprise “Control Tower,” the VP will bridge business strategy and technical execution, enforce vendor rationalization, and champion cultural change to embed Agile ways of working. The position requires exceptional leadership, financial stewardship, and the ability to influence across all levels of the organization. Responsibilities and Qualifications Strategy & Value Realization (40%) Define and lead the SVRO, replacing administrative PMO functions with a value-centric engine. Partner with CIO to steward modernization portfolio and ensure ROI through efficiency savings, vendor rationalization, and automation. Leadership & Operating Model Transformation (30%) Oversee Agile Transformation Lead and program managers. Drive shift to Fusion Teams (Domain Squads) and champion cultural change from “Order Taker” to “Strategic Partner.” Lead talent transformation initiatives, including reskilling project managers into product roles. Governance & Business Engagement (20%) Serve as primary engagement partner for business executives in Operations, Clinical, and Sales. Establish Transformation Steering Committee to resolve escalations and align IT capacity with business priorities. Enforce vendor rationalization governance and optimize contracts to reduce reliance on external contractors. Portfolio Oversight (10%) Manage execution of the 5-Year Roadmap, overseeing interdependencies between Core Systems Modernization, Data Platforms, and Digital Experience initiatives. Develop KPIs and dashboards to measure modernization outcomes and value realization. Serve as escalation point for critical program risks and issues, ensuring timely resolution. Job Requirements Leadership: Demonstrated effectiveness at an executive level in transforming PMOs into Agile/Product Value Offices. Experience managing complex portfolios exceeding $50M. Knowledge: Deep understanding of modern IT operating models (Project-to-Product shifts), SAFe (Scaled Agile Framework), and financial management of IT (TCO, ROI, capitalization in Agile environments). Knowledge of healthcare payer core systems (Claims, Enrollment) preferred. Skills: Ability to translate technical roadmaps into business value propositions (executive storytelling). Strong negotiation skills for vendor consolidation and contract optimization. Change leadership to drive adoption of new operating models across resistance. Experience: Minimum 15+ years progressive management experience. Minimum 10 years in Program/Portfolio Management or IT Strategy. Experience leading large-scale Agile transformations. Education: BS in Business or Computer Science. MBA or advanced degree preferred. PMP, SAFe SPC, or PfMP certifications highly desired. Location: This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays. Key Interfaces Senior Executives Extended Leadership Team Operations, Healthcare Delivery, Finance, HR, Compliance External Vendors About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Provide medical guidance and leadership in utilization management, conduct coverage reviews, and support accreditation efforts. | Must have an MD or DO, current PA license, at least 5 years clinical experience, and 3+ years in managed care or quality management. | Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” The Medical Director provides medical guidance and support to the full spectrum of Capital’s Clinical Utilization Management activities and programs. Supports appropriate Utilization Management goals and objectives. Provides professional leadership and direction to the functions within the Utilization Management Department. *This is an independently contracted role, approximately 15-20 hours/week, at least one weekend every other month, as well as rotating Holiday coverage. *To be considered, you must have a current license to practice in the state of PA Responsibilities and Qualifications Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements Engage with requesting providers as needed in peer-to-peer discussions Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy Makes coverage determinations in instances where requested services do not meet medical necessity criteria or where benefit exclusions require medical evaluation. Makes medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review. Provides Medical Director leadership to Vendor relationships as directed by the Managing Medical Director. Supports organizational accreditation efforts and regulatory review processes: Prior- Authorization, Concurrent Review, Medical Claims Review, Case Management, Disease Management, Pharmacy Management, and Health Education programs. Performs other related duties and assignments as directed. Knowledge: Knowledge of current and emerging medical treatment modalities. Familiarity with National Committee for Quality/URAC standards. Skills: Demonstrated public speaking and written communication skills. Experience: A minimum of five years clinical experience, post residency, including both inpatient and outpatient care. At least three years’ experience in managed care, utilization review, and/or quality management. Education, Certification, and Licenses: Minimum requirements include an MD or DO Degree, as well as appropriate Board Certification. Current unrestricted licensure in Pennsylvania as an MD or DO. Currently covered by, or eligible to be covered by, medical liability insurance. Physical Demands: While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds. About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Oversee and strategize the Medicare and ACA Risk Adjustment Program to ensure compliance, accuracy, and optimal outcomes. | Extensive experience in Medicare Advantage Plans, risk adjustment program management, and healthcare regulatory compliance, with leadership experience in healthcare operations. | Position Description The Risk Adjustment Program Director is responsible of the oversight of Capital’s Medicare and ACA Risk Adjustment Program strategy and operations to ensure regulatory compliance, accurate chronic conditions documentation and appropriate care coordination. This role provides strategic and tactical direction of the Program in collaboration with the Stars & Risk Adjustment Sr. Director. Function as a Risk Adjustment subject matter expert and business owner of risk adjustment processes ensuring efficacy, accuracy and compliance with Program that is organized in the following functional areas: Chart Retrieval, Coding (including Coding Quality/HCC Compliance), Analytics/Reporting, and Encounter Data Submissions serving Retrospective and Prospective Program pillars. Responsibilities and Qualifications Duties and Responsibilities: Actively monitor performance, productivity, and staff development activities. Lead and oversight Risk Adjustment functional areas driving optimal outcomes: Chart Retrieval, Coding (including Coding Quality/HCC Compliance), Analytics/Reporting, and Encounter Data Submissions serving Retrospective and Prospective Programs. Guide and oversees the creation, implementation, and monitoring process of the Risk Adjustment Program strategy, objectives, tactics, and initiatives to drive a year over year quality of care improvements, appropriate reimbursement, and compliance with CMS mandates, regulations, and audits. Lead oversight of Risk Adjustment vendors. Lead in the identification, evaluation, and management of risk adjustment vendors. RFPs readiness, potential vendors evaluation, selection, project implementation, etc. Support Vendor Alliance negotiations activities. Support the execution of MSAs, BAAs, contracts, and SOWs with clear compliance and service level agreements. Acts as subject matter expert, maintain up-to date knowledge and interpret applicable federal and state regulations, CMS guidelines and requirements, and Medicare and ACA models transferring knowledge to leadership and cross-functional teams, etc. Implement a governance structure that provides significant oversight and audit readiness. Build statistically sound strategies to evaluate, monitor compliance, and educate senior management of any potential risk and implement appropriate remediation activities. Collaborate with the Government Program Compliance Officer to develop, execute and continually refine a quality assurance program to monitor, audit and improve the CBC Risk Adjustment Program. Develop and implement remediation strategies as needed with individual providers, provider groups, internal teams, etc. Support and guide business decisions, inform financial plans/forecast, bids development, risk adjustment activities and revenue optimization strategies. Collaborate with Actuarial to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals. Ensure the coordination of processes, protocols and data flow between risk adjustment and cross-functional teams like care management, HEDIS, etc. resulting in appropriate follow of care and quality of care improvement’s activities. Lead the creation, implementation and monitoring process of policies and procedures, standard operating procedures, performance guarantees and workflows to drive effectiveness, efficiency and scalability. Lead, develop, and mentor the Risk Adjustment team. Other duties as assigned or requested. Skills: Excellent verbal communication and interpersonal skills. Able to convey complex and/or technical information in a manner that others can understand. Proven success on building and maintaining positive relationships. Exemplary of a highly collaborative team approach. Ability to influence and persuade people to collaborate and execute toward a common goal. Successful record of managing people and multiple projects with excellent results, meeting desired outcomes and goals. Eager to work with sense of urgency aligned with priorities, overcome obstacles, if needed seek for support early driving the best results to positive impact the Company and team goals. Ability to think analytically to resolve issues; solution-focused mindset; creative, innovative, and compliance thinker. Proven leadership experience in an agile and dynamic work environment. Able to connect and influence direct reports and/or team members across the organization driving collaboration /teamwork. Ability to prioritized tasks and shift readily between “big picture” and small-but-critical details. Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions. Advance proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point, etc.), Project Management tools, Teams/WebEx/ZOOM. Mastery of CMS HCC Risk Adjustment coding and data validation requirements. Strategic mindset, action and results oriented keeping the department/units moving forward by making good and timely decisions meeting goals and objectives. Knowledge: Advance understanding of the Medicare and ACA Risk Adjustment models and regulations/enforcements. Strong financial acumen by using financial analysis to develop, evaluate, and/or act on strategic opportunities. Experience: 7 years experience working with Medicare Advantage Plans experience. 5 years experience overseeing and leading Risk Adjustment Program. 3 years experience building and leading efficient operations and successful teams. 5 years of management experience highly preferred. 3 years experience of budget administration. Education and Certifications: Bachelor’s degree in business administration, Health Management/Administration, Data Analytics, Data Science, Finance, Actuarial, Mathematics or Statistics, Public Health or Health-related Sciences; or additional 4 years of relevant experience in lieu of degree. Certified Risk Adjustment Coder Certification is preferred. Physical Demands: While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds. Other: Travel Requirements: Minimal amount 0-25% of time About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Support financial planning, analysis, and reporting activities for FEP, including expense review, variance analysis, and audits. | Requires 3+ years in healthcare finance, strong Excel skills, and a bachelor's degree in a related field; FEP experience is preferred. | Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” The Financial Analyst-FEP is responsible for financial planning, analysis, and reporting activities for FEP. This role will support the financial functions of FEP including administrative expenses, cost allocations, cost submissions, financial reporting, variance analysis, reporting requirements, and audits. This position will also provide FEP finance support to various internal and external stakeholders. Responsibilities and Qualifications Annual preparation of Federal Employee Health Benefit and Postal Employee Health Benefits Programs. Quarterly administrative cost preparation and submission to BCBSA. Monthly review of FEP direct and allocated expenses to FEP. Budget versus actual analysis of the individual programs and combined FEP program. Plan Incentive Program finance measures - preparation and analysis of rate of change drivers. FEP individual product allocation review. Annual Independent Public Accountant (IPA) audit relating to FEP administrative expenses. Financial requests from the BCBSA, Capital FEP Core Team, and government audits. Review of the FEP Administrative Manual, as regulation and guidance shift. Performs ad hoc reporting and other duties as assigned. Location: This position is hybrid, which requires onsite work on Tuesdays and Wednesdays. Experience: 3 years' health plan or healthcare finance experience. Federal Employee Program (FEP) experience strongly preferred. Skills: Strong interpersonal and communication skills, including written and oral Ability to build productive relationships Self-starter with the ability to streamline functions and passion to learn and grow Proficiency with Microsoft Excel is required; familiarity with data query/data management tools (Access) extremely helpful Strong financial analysis foundation creating forecasts and models Strong fluency with Excel formulas and functions Comfort dealing with ambiguity and ability to work independently Excellent analytical and data gathering skills Knowledge: Strong business acumen, knowledge of financial modeling and techniques Education and Certifications: Bachelor’s degree in accounting/finance/economics or related field Physical Demands: While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds. Other: Travel on an as needed basis for external training About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Lead and oversee cross-functional teams to drive strategic alignment, operational excellence, and modernization initiatives, including agile transformation and automation. | Minimum 7 years of experience leading large-scale transformation initiatives, expertise in agile methodologies, automation, and healthcare industry operations. | Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” The Sr. Director, Business Engineering leads and integrates cross functional teams to drive strategic alignment, operational excellence, and innovation. Responsible for modernizing business processes, optimizing technical solutions, and fostering collaboration across business and technical stakeholders. Champion the transformation from traditional delivery models to agile methodologies. Responsibilities and Qualifications Provide strategic direction and oversight to teams focused on analysis, development and configuration, while ensuring alignment with organizational priorities. Lead departmental and cross-functional corporate initiatives to optimize business processes, systems, and solutions. Serve as project sponsor/owner, as appropriate, and engage teams/staff for implementation and ongoing support. Drive transformation from waterfall to agile methodologies, building agile capabilities and fostering a culture of continuous improvement. Oversee modernization efforts, eliminating technical configuration debt and implementing best practices for configuration management. Provide oversight for vendor relationships, negotiations, and contract oversight. Champion automation and AI adoption to enhance operational efficiency and business outcomes. Build strong relationships with business stakeholders and technical leaders to drive innovation and consensus. Mentor and develop team leaders and staff, fostering accountability and professional growth. Manage budgets, resources, and performance metrics for all sub teams. Ensure effective communication and collaboration between sub teams and executive leadership. Stay abreast of industry trends, regulatory changes, and emerging technologies. Skills Demonstrated ability to lead large, multi-disciplinary teams and drive organizational change. Ability to facilitate cross-functional collaboration and influence stakeholders. Expertise in optimizing technical and configuration processes, including modernization and debt elimination. Knowledge Comprehensive understanding of business engineering principles, systems development life cycles, and process improvement methodologies. Knowledge of healthcare industry operations and regulatory requirements. Familiarity with agile frameworks, automation tools, and AI applications. Experience Minimum 5 years of leadership experience, including managing multiple teams or large-scale initiatives. Minimum 7 years’ experience leading transformation from waterfall to agile methodologies. Experience implementing agile methodologies and managing transformation initiatives. Experience implementing automation and leveraging AI technologies. Experience with Quality Assurance and Testing Experience with technical modernization, configuration management, automation, and AI. Experience in healthcare, insurance, or related industries preferred. Experience with core operational and care management platforms (specifically Facets, NetworX, TruCare) is preferred. Location: The preferred classification for this role is hybrid, which requires onsite work on Tuesdays and Wednesdays. Education, Certification, and Licenses Bachelor’s degree in Business, Engineering, MIS, or related field required. 11 years relevant experience in lieu of degree. Work Environment & Physical Demands Standard office environment; occasional travel may be required. While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds. About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.