UM Nurse Reviewer

Pay Range:

Please emailif you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI our greatest resource is our people.

We come from varying backgrounds different cultures and unique experiences. We are hard-working caring and creative individuals who collaborate support one another and grow together. Passion empathy and understanding are at the forefront of everything we donot just for our members but for our employees as well.

We recognize that to do your best work you have to be your best self.
Its why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health dental and vision insurance as well as programs that support your mental health and well-being. We pay competitively offer bonuses and investment plans and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where youre at in the organization youre an integral part of our team and your input thoughts and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

Were dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality affordable and equitable care. To further improve the health and well-being of our fellow Rhode Islanders we regularly roll up our sleeves and get to work (literally) in communities all across the statebuilding homes working in food pantries revitalizing community centers and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can our associates receive additional paid time to volunteer.

What you will do:

• Conduct pre and post payment review of inpatient admissions outpatient services and other procedures to assess the appropriateness and continuity of care.
• Apply all aspects of the medical review function including pre-authorization concurrent review screening for quality-of-care issues and discharge planning. Document rationale for medical decisions made.
• Identify at-risk members who would benefit from health management programs through comprehensive health assessments.
• Monitor and evaluate patients plan of care and identify potential issues through telephonic outreach. Recommend appropriate interventions.
• Promote member and provider satisfaction. Provide continuity and consistency of care by building positive relationships between member and family physicians provider care coordinator and health care plan. Represent corporation in a responsible and professional manner.
• Participate in department initiatives and projects.
• Perform other duties as assigned.

What youll need to succeed:

• Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC)
• Three to five years acute medical or clinical experience or experience in utilization reviewed.
• Valid Drivers License (On-site only)
• Understanding of utilization review techniques including all aspects of the medical review function including pre-authorization concurrent review and discharge planning
• Understanding of health care delivery system access points and services
• Correct application of health care management guidelines
• Ability to navigate the healthcare delivery system
• Advanced analytical skills with the ability to interpret and synthesize complex data sets
• Good business acumen and political savvy
• Knowledge of business process improvement techniques and strategies
• Excellent verbal and written communications skills
• Negotiation skills
• Presentation skills
• Decision-making skills
• Good problem-solving skills
• Ability to interface with employees at all levels
• Ability to effectively navigate ambiguous situations with limited direction
• Excellent organizational skills and ability to successfully prioritize multiple tasks
• Ability to handle multiple priorities/projects

The extras:

• Bachelors Degree in Nursing
• Certified Case Management certification Certified Professional Utilization Review certification
• Experience working in a managed care/health maintenance organization

Location:
BCBSRI is headquartered in downtown Providence conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states pending approval from the Human Resources Department: Arizona Connecticut Florida Georgia Louisiana Massachusetts North Carolina Oklahoma Rhode Island South Carolina Texas Virginia
  

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do and it strengthens our ability to meet the challenges of todays healthcare industry. BCBSRI is an equal opportunity employer.

The law requires an employer to post notices describing the Federal laws. Please visit to view the Know Your Rights poster.