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.<br><br>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.<br><br>Candidates applying to this remote nursing position can live in one of the following states: Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas.<br><br>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.<br><br><strong>What You'll Do<br><br></strong><ul><li>Conduct 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.</li><li>Educate providers about member benefits, coverage, and provider networks, as well as utilization management processes and procedures.</li><li>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.</li><li>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.</li><li>Collaborate and consult with healthcare providers, internal team or utilization management specialists, nurses, physicians, medical directors, and pharmacists to ensu8re medically appropriate, high-quality cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.</li><li>Collaborate 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.</li><li>Act as a resource within the department and to other departments regarding medical management issues and activities.</li><li>Maintain compliance by knowing, understanding, and adhering to Medicare Advantage, URAC accreditation standards and other regulatory requirements.</li><li>Responsible for maintaining professional licensure and practicing within the scope of licensure.</li><li>Responsible for completion of special projects; examples may include training new hires, provider outreach, project work, peer mentor, new system implementation and system training.<br><br></li></ul><strong>To Be Considered For This Position, You Must Have<br><br></strong><ul><li>Associate's degree in nursing</li><li>Three (3) years’ clinical practice experience in a health care setting</li><li>Must hold a current, unrestricted Registered Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates.</li><li>Must have demonstrated previous experience working in Medicare Advantage and Managed Care organizations. Must have relevant experience aligned with the role: Medicare or Commercial Insurance </li><li>Experience in discharge planning, utilization management, case management, or disease management.</li><li>Based on area of assignment, must be able to work rotating weekend/holiday shifts as needed<br><br></li></ul>An equivalent combination of education and experience may be substituted for this requirement. The ability to meet or exceed the attendance and timeliness requirements of their departments.<br><br>The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.<br><br>To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required.<br><br>Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.<br><br><strong>The Strongest Candidates For This Position Will Also Possess<br><br></strong><ul><li>Bachelor’s degree in healthcare field</li><li>Clinical experience in multiple levels of care</li><li>Knowledge of accreditation standards and regulatory requirements<br><br></li></ul>Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.<br><br><em>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.</em>