Utilization Mgmt Specialist

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

This position is responsible for receiving inquiries into the department, determining if a medical or pharmacy review decision is required, coordinating authorizations for review, completing the screens documentation as well as completing the necessary correspondence between internal & external customers via various means of communication. These inquires can come in a variety of sources, such as telephone, faxes, electronically and in paper. This role is responsible for ensuring medical records are handed appropriately and distributed accurately. This individual is the authorization subject matter expert for the department, can handle confidential information in confidence, & is able to provide a high level of customer service at all times. This position does not include activities that require evaluation or interpretation of clinical information.

Candidates applying to this position may be hybrid or remote and can live in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas.

What you'll do:

• Responsible for maintaining, receiving, verifying medical or pharmacy documentation.
• Determines if medical or pharmacy decisions are required.
• Coordinates authorization for review in Medical Management System.
• Regular correspondence with members, providers, & other internal departments (CSC, Nurses, Physician Reviewers, Pharmacists, Provider Relations, Marketing, etc.).
• Ability to navigate through various systems to complete day-to-day tasks.
• Reviews medical or pharmacy information to ensure all necessary information is received.
• Reporting & research, unit and user testing, as needed.
• Responsible for abiding by all applicable state and federal regulations as well as the BCBSA and BCBSNE mandates related to claims, preauthorizations, including URAC guidelines and timeliness.
• Work with internal staff to ensure that URAC accreditation is maintained.
• Responsible for meeting internal quality and production standards, as well as Service Level Agreements (SLA’s) for the team.
• Responsible for communicating with external customers, providers and other Blues Plans.
• Weekend Rotation: Approx. every 4-6 weeks, working 1 hour on Saturday and 1 hour on Sunday.

To be considered for this position you must have:

• Associate's Degree or an equivalent combination of education and/or experience may be substituted for this requirement.
• 1 year of experience in a health care related field.
• Ability to multi-task.

The strongest candidates for this will also possess:

• Bachelor's Degree.
• Medical Office experience.

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.