This position is a physician leader who provides leadership in utilization, prior authorization and case management for Blue Cross Blue Shield 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..
This position is does have the option to work-from-home full-time.
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 and 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:
- Medical Doctor (MD) or Doctorate of Osteopathy (DO)
- Seven (7) years of experience in Health Care Delivery System (e.g., Clinical Practice and Health Care Industry)
- 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 strongest candidates for this position will also possess:
- Family Practice or Internal Medicine experience
- Prior experience in Healthcare insurance (on payer side)
We strongly believe that diversity of experience, perspectives, and background will lead to a better workplace for our employees and a better product for our customers and members.
Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans
Blue Cross and Blue Shield of Nebraska is an Independent Licensee of the Blue Cross and Blue Shield Association