Manager Medical Review
Bcidaho

Blue Cross of Idaho is seeking a leader over the Medical Review team to ensure the delivery of medically necessary and appropriate, cost-effective care through the performance of accepted case management, transitions of care and medical review practices. Assure accurate and timely medical necessity reviews of Medical and/or Behavioral Health (BH) prior authorizations, concurrent review, pre-payment medical claims, post-payment provider inquiries and member appeals for all lines of business. Work in collaboration of the leadership team on total cost of care for membership lines of business.

We are looking for a Manager with:

Experience: 7 years' relevant experience to include leadership

Education: Associates Degree in Nursing or Bachelor's Degree in Social Work; or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)

Licenses/Certifications: Must hold one of the following:

• Valid unrestricted Idaho Registered Nurse Licensure
• Valid unrestricted Idaho Social Work Licensure

What your day will look like:

• Implement effective operation processes and lead process improvement work groups within the department and cross functionally.
• Implement initiatives to increase provider and member satisfaction. Oversee analysis of key performance metrics to identify areas in need of training and improvement, as well as the identification of potential workflow improvements.
• Develop and interpret policies, procedures, service standards, and workflows to support the consistent application of practices across the functional area and compliance with regulations.
• Operational responsibility for compliance activities and associated reporting.
• Ensure effective workflows, maximizes system efficiencies, monitors quality performance measures, and confirms appropriate completion of work assignments.
• In collaboration with senior leadership, designs, develops, and implements focused functional area strategies.
• Assist in preparing an annual operating budget that reflects the forecasted needs of the department and controls expenditures to assure adherence to approved budgets.
• Performs other duties and responsibilities as assigned.

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

This job has expired.