Blue Cross and Blue Shield of Nebraska · 15 hours ago

Utilization Mgmt Specialist

Remote Nebraska

Full-time

Remote

Entry Level

1+ years exp

Maximize your interview chances

Insurance

Comp. & Benefits

Insider Connection @Blue Cross and Blue Shield of Nebraska

Discover valuable connections within the company who might provide insights and potential referrals.
Get 3x more responses when you reach out via email instead of LinkedIn.

Responsibilities

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.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Medical Management SystemHealth care experienceAssociate's DegreeMedical Office experience