Blue Cross and Blue Shield of Nebraska (BCBSNE) is more than just an insurance company; we exist to be there for people in the best and hardest moments of their lives.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it!

As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

BCBSNE is happy to offer four work designations for our Omaha area employees: 100% in-office, Hybrid – 3 days in office, Hybrid – 2 days in office, 100% remote. Occasional visits to the office.

What you'll do:

• Follow the nursing process of assessment, planning, implementation, and evaluation of member-centric goals and interventions for members enrolled in the case management program.
• Certification and authorization reviews to assess the medical necessity of inpatient admissions, outpatient services, out-of-network services, and appropriateness of treatment setting by utilizing and accurately interpreting applicable medical policy, clinical criteria, standards of care, contract language, benefits, and member eligibility. Facilitate appropriate and timely transitions of care utilizing member’s contract language and clinical criteria. Identify members at risk for post-discharge complications or potentially preventable readmissions and follow-up with members after return home to ensure member is able to obtain medically necessary care, understands discharge instructions and plan of care, understands warning signs of complications and knows what actions to take to address changing health status.
• Responsible to collaborate and consult with healthcare providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.
• Screen and triage members for levels and types of nurse advocacy and medical management programs, including but not limited to: discharge follow-up for potentially preventable readmissions, onsite visit program, care coordination, light touch care management, member outreach, palliative and hospice care management, and complex case management.
• Act as a resource within the department and to other departments regarding medical management issues and activities.
• Educate members about their benefits and coverage, and guide members to appropriate programs, community resources, and in-network providers.
• Facilitates accreditation by knowing, understanding, and adhering to accrediting and regulatory requirements and standards
• Responsible for maintaining professional licensure and practicing within the scope of licensure.

To be considered for this position, you must have:

• Associates Degree in Nursing or Certified Practical Nurse and three (3) years clinical practice experience in a health care setting.
• The Nurse Care Manager must hold a current, unrestricted Registered Nurse or Licensed Practical Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates.

An equivalent combination of education and experience may be substituted for this requirement.

The ability to meet or exceed the attendance and timeliness requirements of their departments.

The ability to work well in a team environment, and be capable of building and maintaining positive relationships with other staff, departments, and customers.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed 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. Other duties may be assigned.

The strongest candidates for this position will also possess:

• Bachelor's Degree in Healthcare field
• Certification in Case Management or Managed Care
• Clinical experience in multiple levels of care
• Experience in discharge planning, utilization management, case management, or disease management
• Knowledge of accreditation standards and regulatory requirements
• Medicaid and Medicare Care Management experience

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans