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Blue Cross and Blue Shield of Nebraska (BCBSNE) is more than just an insurance company; we exist to be there for people in the best and hardest moments of their lives.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there\'s no greater time for forward-thinking professionals like you to join us in delivering on it!

As a member of Team Blue, you\'ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

*BCBSNE is happy to offer four work designations for our Omaha area employees: 100% in-office, Hybrid - 3 days in office, Hybrid - 2 days in office, 100% remote. *

This position is a physician leader who provides leadership in utilization, prior authorization and case management, and utilization management and drug utilization management appeals for BlueCross BlueShield of Nebraska. The individual is responsible for enhancing relationships with providers and facilities, make utilization and prior authorization determinations, assist in case management and be a project manager for medical management programs.

What you\'ll do:

1. Oversee utilization review/quality assurance, directing case management while located in a state or territory of the United States and holding an active, unrestricted license in the same licensure category as the ordering Provider; or as Doctor of Medicine, or Doctor of Osteopathic Medicine

2. Support the Medical Management staff ensuring timely and consistent responses to members and providers.

3. Act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams

4. Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities

5. Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise

6. Craft and implement interventions that improve outcomes

7. Provide alternative approaches that can improve practice performance while achieving similar or greater clinical quality

8. Conduct peer to peer conversations with the attending physician or ordering providers.

To be considered for this position, you must have:

  1. PHD in Medicine (M.D or D.O) and seven (7) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
  2. Board Certified in an American Board of Medical Specialties Board, and a current, unrestricted license to practice medicine in a state or territory of the United States, including post graduate direct patient care experience required.
  3. Nebraska current, unrestricted clinical license.
  4. Three (3) years of direct clinical care in private and/or academic practice

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

Blue Cross and Blue Shield of Nebraska is an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Disabled/Veterans