Temporary Employee- Nurse Reviewer

Temporary Employee- Nurse Reviewer

Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, Rhode Island, United States of America
Req #2033

Friday, January 24, 2025

Please email *** if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Schedule: Hybrid or Remote
Compensation: $33.56 - $50.38

Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.

Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.

Why this job matters:
Optimize member benefits to promote effective use of resources. Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the medical necessity and appropriateness of services on-site or in-house. Discuss cases with attending physician and other health care professionals. Prepare and refer concerns to plan Medical Directors.
What you will do:
Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the appropriateness and continuity of care.
Apply all aspects of the medical review function, including pre-authorization, concurrent review, screening for quality-of-care issues, and discharge planning. Document rationale for medical decisions made.
Identify at-risk members who would benefit from health management programs through comprehensive health assessments.
Monitor and evaluate patient's plan of care and identify potential issues through telephonic outreach. Recommend appropriate interventions.
Promote member and provider satisfaction. Provide continuity and consistency of care by building positive relationships between member and family, physicians, provider, care coordinator, and health care plan. Represent corporation in a responsible and professional manner.
Participate in department initiatives and projects.
Perform other duties as assigned.

What you need to succeed:
Unrestricted Rhode Island Nursing License
Three to five years acute medical or clinical experience or experience in utilization reviewed.
Valid Driver's License (On-site only)
Understanding of utilization review techniques including all aspects of the medical review function, including pre-authorization, concurrent review and discharge planning
Understanding of health care delivery system access points and services
Correct application of health care management guidelines
Ability to navigate the healthcare delivery system
Advanced analytical skills, with the ability to interpret and synthesize complex data sets
Good business acumen and political savvy
Knowledge of business process improvement techniques and strategies
Excellent verbal and written communications skills
Negotiation skills
Presentation skills
Decision-making skills
Good problem-solving skills
Ability to interface with employees at all levels
Ability to effectively navigate ambiguous situations with limited direction
Excellent organizational skills and ability to successfully prioritize multiple tasks
Ability to handle multiple priorities/projects

Extras:
Bachelor's Degree in Nursing
Certified Case Management certification, Certified Professional Utilization Review certification
Experience working in a managed care/health maintenance organization.

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
In-office: onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit /eeoc.gov/employers/eeo-law-poster to view the "EEO is the Law" poster.
Other details
Pay Type
Hourly


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