BlueCross BlueShield of Western New York

About BlueCross BlueShield of Western New York


Job Category:



United States

Postal Code:


Approximate Salary:

Not Specified

Position Type:

Part Time

RN Utilization Management

Posted: 10/5/2018

Auto req ID 1999BR Company BlueCross BlueShield of WNY About Us BlueCross BlueShield of Western New York is a division of HealthNow New York Inc., one of New York’s leading health care companies that provides access to quality health care and solutions for members throughout Upstate New York. Since 1936, BlueCross BlueShield has helped millions of people gain access to health care. Headquartered in Buffalo, NY, the company is an independent Licensee of the BlueCross BlueShield Association. As the region’s leading health plan, serving over 800,000 members, BlueCross BlueShield believes in taking small steps towards healthier living. You can visit our website at Title RN Utilization Management Position Posting Location Buffalo Status Part Time Regular Hours 24 Job Description Assists in ensuring that quality, cost- effective care is delivered to members of all product lines of HealthNow NY Inc. Assists in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits by applying Utilization processes such as prior authorization for inpatient/ outpatient services/ appeals / claims/ inquiry review under the supervision of the Manager or Supervisors of that department. Maintains adherence to established Policy and Procedures, Quality Improvement processes and Compliance Standards. Primary Responsibility Performs either pre or post service review for medical necessity utilizing criteria, medical policy and submitted medical information. Prepares any case that does not meet medical necessity to submit to a Medical Director. Post review, informs member, MD and/or facility of the decision in a written document and/or an oral response. May prepare various correspondences including Initial Adverse Determination, Final Adverse Determination, approval or a Last Covered Day within required time frame guidelines. Utilizes multi computer applications to effectively perform duties. Triages provider requests to comply with regulatory requirements; applies appropriate timeframes to meet regulatory requirements for requesting medical records or sending out the decisions. Maintains compliance with HIPAA (Health Insurance Portability and Accountability Act) for all work. Utilizes and applies knowledge and understanding of CPT procedure codes, HCPC (DME) codes and ICD (Diagnosis) codes in performance of duties. Travel and communication with facilities and Provider community, in the course of duties, as necessary. Performs other related duties as required. Knowledge and Skills Preferred experience in utilization management, managed care, health insurance industry, and the provider community Public communication and presentation skills Computer applications; including , but not limited to: MS Word, MS Excel, MS PowerPoint, MS Access, Visio, Lotus Notes, Internet Excellent organizational skills and attention to detail Must be able to work in a fast-paced environment with daily work processing deadlines High degree of business maturity and demonstrated confidentiality Effective oral and written communication skills. Ability to prepare accurate and timely documentation. Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record) IF applicable to the job responsibilities, i.e., on-site Qualifications External Contacts: UM tasks and actions require interaction with provider offices, facilities, vendors, member and external regulatory agencies. Experience Bachelors Degree preferred. NYS RN license is required. Minimum three (3) years of clinical experience required. Education Required Education:Associates Degree (Nursing) License Registered Nurse Working Conditions Must be able to accommodate local travel. Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record) Irregular hours Must be able to accommodate alternate shifts/days Must be able to occasionally attend off-site meetings, events, conferences Must be able to work in an office environment Must have ability and access to work from remote location such as home Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc) Physical Effort: Minimum; typical of most office work. Mostly sedentary work. Prolonged Sitting Reaching Repetitive Motion Vision Req: Close vision (clear vision at 20 inches or less) Vision Req: Distance (clear vision at 20 feet or more) Walking Weight: lift/carry/push/pull under 10 lbs. EEO Statement All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status. Removal Date 02-Oct-2019

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