Manager Government Utilization Management | bcbs remote job ID-11720

December 17, 2024

Applicants must be eligible to begin work on the date of hire. Applicants must be currently authorized to work in the United States on a full-time basis. ARKANSAS BLUE CROSS BLUE SHIELD will NOT sponsor applicants for work visas in this position.

Arkansas Blue Cross is only seeking applicants for remote positions from the following states:

Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Minnesota, Mississippi, Oklahoma, South Carolina, Tennessee, Texas, Virginia and Wisconsin.

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Job Summary

The Manager Government Utilization Management is responsible for the clinical review of all lines of business for government plans prior to, and during inpatient adminssions, and outpatient procedures. The role evaluates the efficiency and appropriateness for inpatient stays and outpatient procedures for medical necessity through review with evidence-based criteria of cliincal guidelines and policies. The incumbent promotes quality toward cost effective outcomes based on evidence. Incumbent serves as a consultant to less skilled nurses to review and/or collaborate when review determination cannot be met based on initial clincal review.

Requirements

EDUCATION

BSN degree in nursing preferred; MSN preferred. Related health degree will be considered along with appropriate, active RN license as stated below.

CERTIFICATIONS & LICENSES

Registered Nurse (RN) license, active and unencumbered state license in the state where job duties are performed is required

EXPERIENCE

Seven (7) years’ clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing (With Masters’ degree, five (5) years’ practice nursing experience as described above will be considered.)

Five (5) years’ leadership experience (role, project management, team leader, etc.)

Minimum four (4) years’ experience working in utilization management including inpatient, outpatient, and post service prepay

Minimum three (3) years” experience and knowledge of health care regulations, compliance requirements and guidelines specifically related to government programs

Demonstrated experience working in government business such as Medicare managed care, including regulatory and compliance requirements or Medicaid government product strongly preferred

Experience with MCG Care Guidelines and InterQual knowledge of IPUM and OPUM

Experience working with and managing Local and National Coverage Determinations

SPECIALIZED SKILLS & ABILITIES

Ability to work with physicians and other professionals to develop improved utilization of effective and appropriate services

Excellent verbal and written communication skills with providers, members, and internal stakeholders

Demonstrated ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others

Proficiency in software applications that include, but are not limited to, Microsoft Suite Applications, electronic medical records, and other health care management systems.

Ability to work with minimal guidance; seeks guidance on only the most complex tasks

Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action

Strong analytic skills to assess utilization data identify trends and develop strategies to improve efficiencies and effectiveness.

Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage effectively

Skills

Responsibilities

Adheres to URAC Standards and state mandates for all states represented by members as well as federal regulations for all utilization management reviews, Collaborates with other teams within the Medical Management Area, Customer Service and Claims Processing areas for all government plan lines of business, Corporate Medical Director, legal team, and case managers within the Enterprise, Communicates directly with internal and external physicians and facilities, providers/designees for the medical necessity of healthcare services, Cooperates and workds effectively with all department and division staff to facilitate services to m embers and providers of care, Facilitates appropriate cost-effective and cost-containment measures, Makes decisions based on facts and evidence assuming responsibiltiy for those decisions, Manages the hiring, coaching/training, employee development and performance management of assigned team, Monitors cases for medical necessity, quality of care, and level of care, Participates in continuous quality improvement activities, Practices utilization management activities within the scope of practice, Remains current with medical and surgical procedures, products, and general trends in health care delivery, Remains current with ongoing changes in medical practice by use of evidence-based guidelines and medical policy, Serves as a consultant to less trained nurses to review and/or collaborate when review determination cannot be met based on initial clincial review, Serves as a resource for non-clinical staff, Works incoming and assigned outbound calls to/from providers and facilities daily

Certifications

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel – Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

DISCLAIMER

Other Jobs You May Be Interested In

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

5. HOW DO YOU PROCESS INFORMATION?

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

8. HOW TO PRIORITIZE WORK?

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

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