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Responsible for the identification and development of utilization management functions, services and associated deliverables related to local Blue Plans FEP, as well as other Federal Employee Program (FEP) initiatives. Functions as a clinical and technical expert, managing relationships with Plan contacts and providing tactical guidance to Plans regarding utilization management. Supports the implementation of program models to increase the value of services for Plans and internal customers. Participates and may lead larger more complex projects. Resource to Plans for FEP-related information regarding Utilization Management, Precertification, and Prior Authorization Programs and budget.
- Acts as a liaison, resource, and partner with Plans, internal BCBSA staff, and external parties, providing guidance on utilization management activities, ensuring development and/or implementation of required strategies, programs, and products, obtaining Plan input/feedback.
- Participates in Accreditation workgroup activity. Manages correspondence review for member in accordance with accreditation standards and FEP provisions. Identifies critical issues and manages variance within BCBSA departments and/or Plans to achieve a win-win outcome.
- Translates trend information into strategic action plans resulting in value-added resources and or programs that address Plan business needs and supports Federal Employee Program (FEP) strategic initiatives. Lead or participate on team to take recommendation(s) to implementation, Delegates key accountabilities to other team members.
- Fosters collaborative relationships with Care Management to ensure consistent and effective messaging. Resolves complex issues using available resources and expertise in support of division budget and objectives. Significantly contributes to cross-functional teams.
- Proven understanding of administrative databases and their application to projects, in addition to a facility with analytic tools
- Demonstrated presentations skills including the ability to plan, facilitate and present at meetings, conferences and to management
- Active Registered Nursing License
- Certification as Case Manager or eligibility to become certified. Certification to be obtained within first year of employment
- A Bachelor’s degree in a clinical field from an accredited university
- A minimum of five years of experience with Utilization Management in a managed care setting
- Experience with the URAC/NCQA accreditation survey process
- A minimum of seven years related business experience which demonstrates knowledge and understanding of PPO operations, business practices and processes, as well as knowledge of corporate goals
- Proficiency with the use of a variety of software applications (e.g., Microsoft Project, Word, Excel, and PowerPoint)
Company: Blue Cross Blue Shield Association
Vacancy Type: Full Time
Job Location: Washington, DC, US
Application Deadline: N/A