Job Information
Blue Cross and Blue Shield of Louisiana Supervisor, Utilization Review in Baton Rouge, Louisiana
We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.
Residency in or relocation to Louisiana is preferred for all positions.
POSITION PURPOSE
Responsible for overall unit performance. Responsible for personnel administration including selection, coaching, motivation, discipline, continuous improvement and compliance. Responsible for coordinating, processing and managing the evaluations of medical and claim information to ensure proper administration of contractual terms. This includes determinations about billing practices, medical necessity, medical appropriateness, levels of care, and relationships between medical conditions and services while maintaining compliance with regulatory guidelines.
NATURE AND SCOPE
Manages People
This role directly manages 8 to 13 workers
This role reports to this job: DIRECTOR, UTILIZATION REVIEW;MANAGER, UTILIZATION REVIEW
Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Healthcare providers and subscribers to obtain medical information. Obtains request for reviews from and notifies determinations to BAD, ITS, NASCO, FEP, BMS, and legal.
QUALIFICATIONS
Education
Bachelor's in nursing, business administration, healthcare or a related field is required
Current, unrestricted RN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided can be used in lieu of a Bachelor's degree
Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided as well as two years of related experience can be used in lieu of a Bachelor's degree
Four years of related healthcare payer and/or business administration experience can be used in lieu of a Bachelor's degree
Work Experience
3 years of direct patient care/clinical experience to include three years managed care experience or three years BCBSLA Care Management experience with progressive levels of responsibility and expertise required
1 year of leadership experience is required.
Skills and Abilities
Ability to review claims history in a commercial medical claims system and generate a basic report is required.
Expert in use of standardized data exchange code sets and medical terminology is required.
Must demonstrate the ability to critically evaluate clinical, claim and benefit information and make independent decisions and anticipating impacts and needs.
Comprehension and application of provider and benefit contract terms is required.
Excellent oral/written communication skills as well as human relation skills are required.
Excellent organizational and analytical skills are required.
Must maintain proficiency in nursing practice and state licensure through pertinent continuing education.
Ability to make decisions, prioritize, find solutions, and work independently are required.
Excellent interpersonal communication and administrative skills are required.
Requires working knowledge of MS Office and related software.
Licenses and Certifications
Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided
Current, unrestricted RN license And/Or Compact State Licensure License in the state of Louisiana and/or in the required jurisdictions, or where services are provided is required
Certification in Professional Coding, Utilization Review, Utilization Management, Quality Review, Case Management or Chronic Disease Management, or HIAA is required
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
Administers all HR functions, including but not limited to, hiring, terminating, conducting performance reviews, setting performance standards, approving work schedules, assigning and directing workload, training and developing staff, coaching, etc. to ensure team goals are met.
Reviews medical claims or requests for services and applies medical judgment and /or criteria in determining the benefits for pre-services and post-services according to contractual benefits, provider contracts, and limitations, (i.e. pre-existing, workman’s compensation, riders, contractual exclusions, billing practices, cosmetic or investigational procedures and medical necessity).
Completes correspondence correctly when necessary, to providers and subscribers to ensure that customers are aware of the determinations and appeal processes/rights meeting all regulatory standards.
Prepares documentation of medical information, completes research, makes recommendations and refers potential denials to the Medical Directors and Management when necessary to ensure compliance with URAC standards, MNRO and DOL laws and regulations.
Assists others units as necessary for maintaining department timeliness standards and represents unit and department on cross-departmental teams leading work groups to implement projects. Performs data analysis and makes program improvements.
Additional Accountabilities and Essential Functions
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
Perform other job-related duties as assigned, within your scope of responsibilities.
Job duties are performed in a normal and clean office environment with normal noise levels.
Work is predominately done while standing or sitting.
The ability to comprehend, document, calculate, visualize, and analyze are required.
#LI_MS1
An Equal Opportunity Employer
All BCBSLA EMPLOYEES please apply through Workday Careers.
PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
Additional Information
Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.
JOB CATEGORY: Insurance