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 us.
Residency in or relocation to Louisiana is preferred for all positions.
Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity.
POSITION PURPOSE
Staff in the Population Health and Health Services area: Utilize a collaborative process to assess, plan, implement, monitor and evaluate options and services required to meet the member’s, providers’ and communities’ healthcare needs. Utilizing the disease management referral and assessment process, the disease management nurse will identify the most appropriate resources to promote quality, cost effective outcomes. Utilization Review staff are responsible for providing clinical service and/or member management. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.
NATURE AND SCOPE
- This role does not manage people
- Necessary Contacts: In order to effectively fulfill this position the incumbent must be in contact with:
All internal departments, providers, subscribers, group representatives, reinsurance carriers, Department of insurance, other insurance carriers, and healthcare vendors.
QUALIFICATIONS
Education
- High School Diploma or equivalent required
Work Experience
- 4 years of direct patient care experience required
- Managed Care or claims processing experience and knowledge of medical terminology and ICD 10 codes required
- 1 year of medical review and/or authorization experience preferred
Skills and Abilities
- Prefer knowledge of insurance, reinsurance, and/or customer service operations.
- Ability to research and analyze cases and make appropriate quality and cost effective decisions.
- Must be able to communicate effectively with members, providers, pharmacy staff and fellow employees at all levels of the organization.
- Must be detail oriented, organized, and self motivated.
- Must use appropriate professional judgment and be able to make decisions and delegate work appropriately while working on multiple tasks.
- Working knowledge of related software and office equipment.
- Ability to comprehend Medicare guidelines and assume responsibility for decisions based on these Guidelines is required.
- Knowledge of coding guidelines for ICD, HCPCS and CPT preferred.
Licenses and Certifications
- Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided required.
- CPUR, CPC, or CMCN certification is preferred upon hire; required within 24 months in position.
- A comparable professional medical review or case management certification is preferred.
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
- Assess member’s status by collecting in-depth information about the patient’s situation and functioning to identify needs in order to develop and implement a comprehensive disease management plan that will address needs.
- Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators.
- Implement specific interventions that will lead to accomplishing the goals established in the plan.
- Coordinate by organizing, integrating, and modifying the resources necessary to accomplish the goals.
- Monitor by gathering sufficient information from relevant sources in order to determine the effectiveness of the plan.
- Responsible for meeting targets for staff and unit performance to maximize program value and ensure achievement of department productivity goals.
- Care coordination or Utilization Management as designated by RN and/or clinical leadership.
- Researches and interprets contract benefits to facilitate accurate benefit administration and fulfill product-specific authorization requirements.
- Conducts medical necessity reviews based upon the patient's condition and/or symptoms utilizing medically-accepted review criteria/guidelines, medical delegations and/or policies to provide quality healthcare and meet regulatory requirements.
- Responsible for reviewing, resolving, and responding to issues regarding utilization of benefits. Works closely with internal and external customers to coordinate appropriate care for authorized services.
- Negotiates rate of payment when provider network deficiency exists and accurately calculates and documents care management savings to initiate care management programs, identify product enhancement opportunities, and capture returns on investments (ROI).
- Communicates directly with members and/or providers regarding contract requirements and collects relevant planned care information via telephone to facilitate member management.
- Responsible for timely management for appropriate verbal notifications and/or written materials to ensure compliance with regulatory and/or operational guidelines.
- Responsible for meeting targets for staff and unit performance to maximize program value and ensure achievement of department productivity goals.
- Serves as a technical resource to the non-clinical staff by responding to inquiries regarding the interpretation of clinical information to provide clinical support for non-clinical staff involved in the review process.
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.
An Equal Opportunity Employer
All internal 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 for assistance.
In support of our mission to improve the health and lives of Louisianians, we encourage 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.
We perform 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, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.
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