BlueCross BlueShield
    May 7, 2021
    Omaha, Nebraska
    Job Type
    Work Setting


    Blue Cross and Blue Shield of Nebraska (BCBSNE) is more than just an insurance company; we exist to be there for people in the best and hardest moments of their lives.

    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 provides leadership in utilization, prior authorization and case management for BlueCross BlueShield of Nebraska. The individual  is responsible for enhancing relationships with providers and facilities, make utilization and prior authorization determinations, assist in case management and be a project manager for medical management programs.

    What you'll do: 

    • Oversee utilization review/quality assurance, directing case management
    • Support the Medical Management staff ensuring timely and consistent responses to members and providers.
    • Act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams
    • Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities
    • Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise
    • Craft and implement interventions that improve outcomes
    • Provide alternative approaches that can improve practice performance while achieving similar or greater clinical quality

    To be considered for this position, you must have:

    • Bachelor's degree in a related field and seven (7) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.  An equivalent combination of education and experience may be substituted to meet this requirement.
    • MD or DO Board Certification in recognized specialty including post-graduate direct patient care experience required
    • Three (3) years of direct clinical care in private and/or academic practice
    • 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.
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