Utilization Management Nurse

Blue Cross Blue Shield • Omaha, NE

122d • Remote

About The Position

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. In this remote position you can be located in one of the following states: Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas. This position works collaboratively with health care providers and other team members, including Medical Directors and Pharmacists, to ensure members receive high quality, medically necessary care in a timely fashion in a setting that maximizes benefit coverage and health outcomes in accordance with company policies and procedures.

Requirements

• Associate's Degree in Nursing.
• Three (3) years clinical practice experience in a health care setting.
• The Utilization Management Nurse must hold a current, unrestricted Registered Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates.
• Based on area of assignment, must be able to work rotating weekend/holiday shifts as needed.

Nice To Haves

• Demonstrated previous experience working in Medicare Advantage and Managed Care organizations.
• Bachelor's degree in healthcare field.
• Clinical experience in multiple levels of care.
• Experience in discharge planning, utilization management, case management, or disease management.
• Knowledge of accreditation standards and regulatory requirements.
• Medicare and Medicare Care Management experience.

Responsibilities

• Prospective, Concurrent, Retrospective, and post-service clinical claim certification and authorization reviews to assess the medical necessity of medical and/or behavioral health inpatient admissions, outpatient services, out-of-network services, and appropriateness of treatment setting by utilizing and accurately interpreting applicable medical policy, evidence based clinical criteria, standards of care, contract language, benefits, and member eligibility.
• Educate providers about member benefits, coverage, and provider networks, as well as utilization management processes and procedures.
• Facilitate appropriate and timely transitions of care utilizing member's contract language and clinical criteria coordinates discharge planning with providers for the appropriate level of care (SNF, ARU, LTAC, hospice) or discharge to home.
• Identify members appropriate for care management programs and make referrals to care management nurses, including but not limited to discharge follow-up for potentially preventable readmissions, member outreach initiatives, and complex case management.
• Collaborate and consult with healthcare providers, internal team or utilization management specialists, nurses, physicians, medical directors, and pharmacists to ensure medically appropriate, high-quality cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.
• Collaborates with the Medical Director by referring events not meeting clinical criteria or events needing additional review. Attends weekly rounds to discuss possible high-cost claimants, discharging plans, and concerns for appropriate care or member safety.
• Act as a resource within the department and to other departments regarding medical management issues and activities.
• Maintain compliance by knowing, understanding, and adhering to Medicare Advantage, URAC accreditation standards and other regulatory requirements.
• Responsible for maintaining professional licensure and practicing within the scope of licensure.
• Responsible for completion of special projects; examples may include training new hires, provider outreach, project work, peer mentor, new system implementation and system training.

What This Job Offers

• Job Type: Full-time
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree