Optimize member benefits to promote effective use of resources. Conduct pre- and post-payment review of inpatient admissions, outpatient services, and other procedures to assess the medical necessity and appropriateness of services on-site or in-house. Discuss cases with attending physician and other healthcare professionals. Prepare and refer concerns to plan Medical Directors.
ESSENTIAL JOB FUNCTIONS:
QUALIFICATIONS:Minimum Education and Experience:
Preferred Education, Additional Qualifications, and Experience:
Required Knowledge, Skills, and/or Abilities:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, age, national origin or ancestry, disability, veteran status, sexual orientation, genetic information, sex, gender identity or expression, and any other personal attributes protected by federal, state, or local law. For more information about our commitment to diversity and inclusion, please see our Diversity Report at bcbsri.com/diversityreport.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf to view the "EEO is the Law" poster.
BCBSRI is committed to working with and providing reasonable accommodation to individuals with disabilities. If, because of a disability, you need a reasonable accommodation for any part of our application process, please contact us at (401) 459-1050 for assistance.
During the application process, please allow a minimum of five business days before you contact our office to inquire about the status of your application. If you have any questions regarding your application or during the process, please contact Human Resources by phone at (401) 459-1050 or by email at firstname.lastname@example.org.
Southern New England, Boston, MA, Hartford, CT, Health Data Analyst, RI Health Insurer, Healthcare, Wellness, Provider, Network, Rhode Island, RI, Care Management, Certified Professional Healthcare Management, CPHM, Certified Case Manager, CCM, Accredited Case Manager, ACM, Utilization Review, Med/Surg, Med-Surg, Med Surg, Medical/Surgical, Medical-Surgical, Medical Surgical, Registered Nurse, RN, Coordinator, Coordinate, BSN, Bachelor's Degree in Nursing
In addition to the standard benefits package you would expect, we also offer:
In our ongoing efforts to mitigate the spread of COVID-19, Blue Cross & Blue Shield of Rhode Island will conduct all interviews virtually until further notice. We will continue to review applications for open positions in a timely manner. Thank you for your patience and flexibility as we adapt to the current environment!