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Utilization Mgmt Specialist
This position is responsible for receiving inquiries into the department, determining if a medical or pharmacy review decision is required, coordinating authorizations for review, completing the screens documentation as well as completing the necessary correspondence between internal & external customers via various means of communication. These inquires can come in a variety of sources, such as telephone, faxes, electronically and in paper. This role is responsible for ensuring medical records are handed appropriately and distributed accurately. This individual is the authorization subject matter expert for the department, can handle confidential information in confidence, & is able to provide a high level of customer service at all times. This position does not include activities that require evaluation or interpretation of clinical information.
Credentialing Specialist
This position is responsible for processing credentialing data for new and current network practitioners through data collection and primary source verification requiring compliance with URAC Standards, regulatory accreditation standards, Nebraska State statutes, HIPPA regulations and policies/ procedures for presentation to the Credentialing Committee. Responsible for the maintenance of the credentialing database, coordination with vendor system and provider files to meet credentialing requirements and deadlines.
Medicare Advantage Enrollment Specialist
This role is responsible for the accurate and timely processing of Medicare Advantage enrollment transactions utilizing CMS guidance and Blue Cross Blue Shield of Nebraska policies and procedures. The role is responsible for ensuring accurate enrollment including billing and maintenance of member data by researching and resolving enrollment and billing discrepancies. The role is also responsible for reconciling and correcting enrollment-related issues by building case files sent to CMS for approval and resolution.
Registered Nurse Care Manager
This position will engage at risk members to improve health and financial outcomes through analysis of needs, design, and delivery of interventions. The Nurse Care Manager educates members to understand innovative benefit structures that promote transparency and affordability and empowers consumers to make informed decisions regarding their healthcare options, coverage, and financial risk. They support members in developing self-management skills and adopting positive behavior changes, identifies and addresses barriers to member’s adherence to standards of evidence-based medicine. Identifies resources to assist members in achieving their personal health goals, and proactively incorporates lifestyle improvement and prevention opportunities into member interventions. The Nurse Care Manager assists members to navigate the complex health care settings and ensures they get the support they need throughout the episode of care to optimize health status.

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