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Position Posted
Prospective Risk Specialist
The Prospective Risk Specialist is primarily responsible for providing support to the Risk Adjustment Department. This individual will perform a wide array of administrative tasks, such as ordering and follow up on medical records requested, attach medical records received to electronic member profile and supporting the annual audit. This individual should have experience using medical software with attention to detail to ensure medical record accuracy.
Risk Coding Liaison
Under the direction of the Manager of Risk Adjustment, the Risk Coding Liaison will be responsible for the oversight of Medicare Advantage Risk Adjustment Objectives. This position will participate in the strategy as well as oversee the operational functions related to Medicare Advantage risk adjustment. This position will also serve as the Risk Adjustment Subject Matter expert and will ensure the accurate and compliant execution of Medicare Risk Adjustment activities. This position will primarily work with our vendor partners as well as our physician practices to provide services to our members enrolled in a Medicare Advantage plan.
Supervisor Risk Adjustment Analytics
This position is responsible for the oversight of the analytic functions of the risk adjustment programs area.
Medical Director
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.
Senior Market Operations Specialist
This position is accountable for maintaining an ongoing assessment and interpretation of the Medicare Advantage and Prescription Drug (MAPD) programs and systems to assure the efficient and effective delivery of services. Support key drivers of success in the MA market around member satisfaction, STAR ratings, and all operational functions that support these goals. The individual must assume a self-directed leadership role, work independently, understand project management methodologies, be competent in technical and business analysis and possess superior communication skills while collaborating and maintaining relationships with internal and external staff. This position may also support other senior market products.
Health Network Operations Specialist
Job Profile Summary This position provides support for Provider Services strategic initiatives to optimize business processes. The role is accountable to provide guidance and to communicate the technical and business changes with internal and external customers. The individual will provide analysis and direction, where subject matter expertise is required. The role will require an individual to have strong influence skills, be a strong communicator and be able to think out of the box for ways to see result.
Manager Appeals
This position designs, develops, leads, and manages the Appeals Team. The manager provides leadership and executes decision-making based on subject matter expertise, clinical knowledge, experience and judgment. This position is responsible for solving problems and for maintain strong internal and external working relationships. The incumbent is responsible for the oversight and operations of the Grievance and Appeals Department ensuring that the team operates according to corporate, contractual, state, federal and accrediting agency requirements. Populations served by this team includes the Federal Employees Program (FEP) and commercial PPO members. This individual is knowledgeable of and responsible for compliance with regulatory requirements of both member and provider grievances, including, claims, prior authorizations, medical policy, and reimbursement.
Associate Client Consultant
This position is responsible for the coordination and delivery of reporting and analytics to assigned employer groups of varying sizes, working with BCBSNE account executives, internal business partners, brokers and group leaders. For smaller sized accounts, this individual will be responsible for delivering standard reporting and answering group and broker questions. For larger sized accounts, this individual establishes and maintains a collaborative partnership with assigned groups and brokers to consistently demonstrate the scope of BCBSNE's reporting and analytic capabilities. This person should feel comfortable presenting data to external audiences in partnership with the BCBSNE account team on occasion.

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