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 Blue Cross.

　　Please note that effective Jan. 4, 2022, Blue Cross and Blue Shield of Louisiana implemented a policy requiring any employee who enters any of our offices or who interacts in person with anyone for company business purposes to be fully vaccinated for COVID 19, unless legally entitled to a reasonable accommodation related to religious or medical exemptions. At this time, that policy is suspended and vaccination is not required to enter our facilities. Please note this is subject to change at any point in time to ensure compliance with company policy or government mandates and certain client facing roles may have separate protocols.

　　Residency in or relocation to Louisiana is preferred for all positions.

　　POSITION PURPOSE

　　Responsible for coordinating, processing and managing all in-patient and out-patient claims from a medical standpoint to ensure proper administration of contractual limitations and exclusions to include medical necessity, while maintaining compliance with regulatory guidelines. Responsible for identification of areas for improvement, and formulation of recommendations for solutions. 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

　　This role reports to this job: Departmental Leadership

　　Necessary Contacts: Healthcare providers, subscribers, BAD, ITS, NASCO, FEP, BMS, and Legal.

　　QUALIFICATIONS

　　Education

　　Bachelor's in business administration, healthcare, computer science or related degree is required or

　　In lieu of degree, RN license is required or

　　In lieu of degree, LPN license to practice in Louisiana as well as 2 years of related experience is required or

　　In lieu of degree, 4 years of related experience is required

　　Work Experience

　　3 years of direct patient care/clinical experience which includes two years of managed care is requiredSkills and Abilities

　　Knowledge of standardized code sets and medical terminology is required

　　Knowledge of provider and benefit contracts and the ability to interpret and apply the information is required

　　Must demonstrate the ability to critically evaluate information making independent decisions and anticipating needs.

　　Must demonstrate excellent interpersonal, administrative, and telephone skills.

　　Working knowledge of MS Office and other relevant software is required

　　Demonstrated ability to handle multiple tasks in customer friendly manner and provide expert support to peers while maintaining performance standards is required

　　Licenses and Certifications

　　Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure Must be a Registered Nurse with a current Louisiana license. required

　　Case Mgmt/Social Services\CPUR - Cert Prof Util Review Must be attained within first 24 months in position. required or

　　Non Clinical\CPC and/or CCSP - Certified Professional Coder Must be attained within first 24 months in position. required

　　ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

　　Responsible for identifying areas of improvement, and identifying and vetting potential solutions with supervisor/manager and implementing solutions in a collaborative manner. May serve as a resource to others and train new staff with oversight of supervisor. May assist with gathering information for unit audits.

　　Prepares documentation of medical information, completes research, makes recommendations, and refers potential denials to the Medical Directors and Management when necessary to ensure compliance with URAC standards, MNRO and DOL laws and regulations.

　　Completes correspondence correctly when necessary to providers and subscribers to ensure that customers are aware of the determinations and appeal processes/rights meeting all regulatory standards.

　　Responsible for meeting targets for staff and unit performance as required by company and management standards. Assists supervisor and other units of Care Management maintaining department timeliness standards and participating on cross-department projects.

　　Interacts telephonically with patients and/or providers in order to determine patient care needs, compliance and effectiveness with planned interventions.

　　Utilizes accepted review and LOS criteria in conjunction with appropriate professional nursing judgment to determine medical necessity, accurate length of stay, and discharge needs while maintaining compliance with federal and state regulations and standards. Monitors for, records, and appropriately addresses variances to optimal recovery care path.

　　Utilizes appropriate professional nursing judgment in application of contractual benefits and limitations, administrative directives, and claims policy in order to direct the appropriate course of action throughout the continuum of care.

　　Assesses and establishes a pertinent plan of care/clinical pathway to support optimal patient outcomes anticipating and preventing avoidable variation in utilization of services. Monitors case progression to ensure compliance with plan or need for re-evaluation and adjustment of plan.

　　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.

　　#LI_MS1

　　An Equal Opportunity Employer

　　All BCBSLA EMPLOYEES please apply through Workday Careers.

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　　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 [email protected] for assistance.

　　In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages 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.

　　Blue Cross and Blue Shield of Louisiana performs 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, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

　　JOB CATEGORY: Insurance