Utilization Mgmt Specialist

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.

BCBSNE is happy to offer four work designations for our Omaha area employees: 100% in-office, Hybrid options, and 100% remote. If choosing to work remote, this role can be located in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas.

This position is responsible for reviewing appeals and determining if a medical decision is required, setting up the appeal for review, completing the screens documentation as well as completing the necessary written correspondence once the disposition is made.

What you'll do:

• Research and accept all incoming department correspondence via fax, phone, mail, and email and distribute appropriately. Review appeal setup and verify the correct letters will be sent from the Medical Management Documentation System (MMDS). Pull incoming medical rationale to load the MMDS via appropriate systems.

• Responsible for meeting all State and Federal regulations as well as BCBSA, BCBSNE, and Medicare Advantage mandates related to claims and preauthorization processing such as URAC, DOI, DOL and Legal guidelines.

• Responsible for daily tasks and collaborate with the Appeals Specialist team to ensure coverage and assignment of duties.

• Responsible for determining availability of benefits according to company contracts, Medicare Advantage coverage requirements and endorsements.

• Research and confirm member eligibility prior to medical review.

• Answer and research phone calls and emails from providers, members, Brokers, and Customer Service to provide answers and guidance on the status of an appeal, how to file an appeal and/or route to the correct party for further assistance.

To be considered for this position, you must have:

• High School Diploma or equivalent

• Experience in a health care field and/or insurance auditing

• Familiar with Medical Terminology

• Based on area of assignment, must be able to work rotating weekend/holiday shifts as needed.

The strongest candidates for this position will also possess:

• Two (2) years customer service experience with the good understanding of all lines of business.

• Demonstrated previous experience working in Medicare Advantage and Managed Care organizations.

• Knowledge of accreditation standards and regulatory requirements.

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.