Temporary Employee- Nurse Reviewer

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