The posting
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 a physician leader who will lead development and implementation of strategies that promote medical management, practice transformation, patient satisfaction, improvement to quality outcomes while reducing overall cost for the assigned area. The individual is responsible for enhancing relationships with providers, facilities, and internal/external partners to act as a project manager for the assigned medical management programs (e.g., utilization, prior authorization, case management, Medicare Advantage, etc.).
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:
- Provide clinical oversight of assigned area/s (e.g., utilization review/quality assurance, case management, quality, population health outcomes, and/or cost management).
- Conduct medical necessity reviews for utilization management appeals, including first- and second-level appeals, ensuring determinations are evidence‑based, clinically sound, timely, and compliant with applicable regulatory, accreditation, and plan requirements.
- Support the Medical Management staff and external partners to ensure timely and consistent responses to members and providers.
- Provide clinical expertise and business direction in support of medical management programs through participation in clinical and policy team activities.
- Responsible for utilization review cases (prior authorization, pre-certification, concurrent certification, medical necessary, etc.) predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
- Conduct peer-to-peer conversations with the attending physician or ordering providers.
- Develop relationships with physicians and staff to engage, identify, and disseminate best practices, analyze clinical workflows, and support intervention activities directed towards meaningful quality improvements and reduction of unplanned health care utilization.
To be considered for this position, you must have:
- Doctor of Medicine (M.D or D.O)
- Seven (7) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry
- Board Certified in an American Board of Medical Specialties Board, and an active, current, and unrestricted license to practice medicine in a state or territory of the United States, including post graduate direct patient care experience required
- Active, current, and unrestricted Nebraska clinical license that would allow the incumbent to apply their clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination.
- Three (3) years of direct clinical care in private and/or academic practice.
- Based on area of assignment this role may be required to be completed in Nebraska.
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.
The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.
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.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.
The strongest candidates for this position will also posses:
- 2+ years of managed care experience, preferably with a Medicare Advantage population.
- Demonstrated skills in creating buy-in with internal and external clinician stakeholders to transform clinical care.
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.
