Health Care

applicants

BlueCross and BlueShield of TennesseeChattanooga, TNThe purpose of this position is to coordinate, design, develop and implement efficient processes/programs to meet the needs of the business. This position plays a key role in on-going and new process to support the Government Medical Management / Physician Review area and appropriate departments. This position is responsible for the research, development, and validation of UM and CM reports to ensure accuracy and compliance with business standards.• To monitor workload (queue) and notify the medical director and other appropriate staff of pending cases per contractual protocols. • Monitor and manage MDR scheduling • Manage the on boarding process for newly hired physician (Peoplesoft, security request , etc) • Monitor and manage workload assignments per physician schedules • Handle nurse and bureau calls regarding Medical Director review and appeals issues as they impact the Medical Review Process • Assure all doctor-to-doctor calls are scheduled and that the process is efficient • Assure all workgroups regarding the medical review process are scheduled • Design, review, analysis and present production reports including member and provider appeals, case management and retro reviews for all assigned areas. • Assure maintenance of certifications and compliance standards for all Physician Reviewers. • Serve as committee coordinator for the Medical Director Review Meeting, Medical Director Seminar and other committees as assigned. • Serve as coordinator for Medical Director educational efforts • Manage and coordinate major projects within the area as assigned by the medical director to include the annual budget process. • Manage the Physician Activity Log • Maintain excellent understanding of all contractual requirements, directives, accreditation requirements, etc. for the department to ensure program revisions are compliant with these requirements. • Provide staff assistance and support for Medical Director Educational Efforts • Other duties as directed by the Medical Director, Government Medical Management. Education: • BS in Business Administration, health care or other relevant area or equivalent work experience required • Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law highly preferredExperience:• Minimum 3 years data analysis experience required • UM, clinical or medical terminology knowledge highly preferred • URAC/ NCQA knowledge highly preferred • Minimum 3 years in a leadership roleSkills/Certification:  • Microsoft Word and Excel (only) required • 1 - 3 years of systems knowledge (Fast Track, Facets) • Some travel required • AHIPAA  or Managed Care Certification preferredPlease apply via our career site at:https://www.bcbst.com/about/careers/openings/