Medical Review Specialist I

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 accountable for performing medical review to ensure correct dispositions according to all contracts, related endorsements, government regulations and BCBSNE medical policies

Candidates applying to this remote nursing position can live in one of the following states: Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas. 

What you'll do:

• Responsible for meeting all State and Federal regulations as well as BCBSA and BCBSNE mandates related to claims and preauthorization processing. 
• Responsible for accurate and timely medical review of claims and preauthorization's.
• Responsible for accurate and timely medical review of Customer Service inquiries about claims and preauthorization's. 
• Responsible for determining availability of benefits according to company contracts, endorsements and medical policy. 
• Responsible for determining member eligibility prior to medical review. 
• Responsible for fostering a constructive relationship with all departments within BCBSNE.
• Responsible for maintaining professional licensure and practicing within the scope of licensure.
• Responsible for collaborating and consulting with healthcare providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.

To be considered for this position, you must have:

• Associate degree in nursing or Certified Practical Nurse and three (3) years clinical experience in a health care setting.
• Must hold an active, current, and unrestricted Registered Nurse or Licensed Practical Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates.

The strongest candidates for this position will also possess:

• Bachelor’s degree in healthcare field.
• Certification in Managed Care.
• Clinical experience in multiple levels of care.
• Experience in medical review or utilization management.
• Knowledge of accreditation standards and regulatory requirements.

#LI-DNP

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.