Supervisor, Utilization Review - Behavioral Health

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

Responsible for overall unit performance. Responsible for personnel administration including selection, coaching, motivation, discipline, continuous improvement and compliance. Responsible for coordinating, processing and managing the evaluations of medical and claim information to ensure proper administration of contractual terms. This includes determinations about billing practices, medical necessity, medical appropriateness, levels of care, and relationships between medical conditions and services while maintaining compliance with regulatory guidelines.

NATURE AND SCOPE

Manages People

This role directly manages 5-10

This role reports to this job: Manager, Behavioral Health Operations

Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Healthcare providers, subscribers, claims, appeals, legal, networking, case management, customer service, and compliance.  

QUALIFICATIONS

Education

• Bachelor's in nursing, business administration, healthcare or a related field, masters in social work, counseling, or other behavioral health related field is required.
• Current, unrestricted RN, license in the state of Louisiana and/or in the required jurisdictions, or where services are provided can be used in lieu of a Bachelor's degree
• Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided as well as two years of related experience can be used in lieu of a Bachelor's degree
• Four years of related healthcare payer and/or business administration experience can be used in lieu of a Bachelor's degree

Work Experience

• 3 years of direct patient care/clinical experience to include three years managed care experience or three years BCBSLA
• Care Management experience with progressive levels of responsibility and expertise required
• 1 year of leadership experience is required.

Skills and Abilities

• Ability to review claims history in a medical claims system and generate a basic report is required.
• Must demonstrate the ability to critically evaluate clinical, claim and benefit information and make independent decisions and anticipating impacts and needs.
• Comprehension and application of provider and benefit contract terms is required.
• Excellent oral/written communication skills as well as human relation skills are required.
• Excellent organizational and analytical skills are required.
• Must maintain proficiency in nursing or professional practice and state licensure through pertinent continuing education.
• Ability to make decisions, prioritize, find solutions, and work independently are required.
• Excellent interpersonal communication and administrative skills are required.
• Requires working knowledge of MS Office and related software.

Licenses and Certifications

• Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided.
• Current, unrestricted RN license and/or compact state licensure in the state of Louisiana and/or in the required jurisdictions, or where services are provided.
• Current unrestricted LCSW or LPC license in the state of Louisiana and/or in the required jurisdictions, or where services are provided.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Administers all HR functions, including but not limited to, hiring, terminating, conducting performance reviews, setting performance standards, approving work schedules, assigning and directing workload, training and developing staff, coaching, etc. to ensure team goals are met.
• Reviews medical claims or requests for services and applies medical judgment and /or criteria in determining the benefits for pre-services and post-services according to contractual benefits, provider contracts, and limitations, (i.e. pre-existing, workman’s compensation, riders, contractual exclusions, billing practices, cosmetic or investigational procedures and medical necessity).
• Completes correspondence correctly to providers and subscribers to ensure that customers are aware of the determinations and appeal processes/rights meeting all regulatory standards.
• Prepares documentation of medical information, completes research, makes recommendations and refers potential denials to the Medical Directors and Management when necessary to ensure compliance with URAC and/or NCQA standards, MNRO and DOL laws and regulations.
• Assists others units as necessary for maintaining department timeliness standards and represents unit and department on cross-departmental teams leading work groups to implement projects. Performs data analysis and makes program improvements.

Additional Accountabilities and Essential Functions
 

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account. 

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free. 

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.