Job Description
Perform medical review to ensure correct dispositions according to all contracts, related endorsements, government regulations and BCBSNE medical policies. Responsible for meeting all State and Federal regulations as well as BCBSA and BCBSNE mandates related to claims and preauthorization processing. Accountable for accurate and timely medical review of claims and preauthorization's. Further responsibilities include accurate and timely medical review of Customer Service inquiries about claims and preauthorization's. Determine availability of benefits according to company contracts, endorsements and medical policy. Determine member eligibility prior to medical review. Foster a constructive relationship with all departments within BCBSNE. Maintain professional licensure and practicing within the scope of licensure. Collaborate and consult with healthcare providers, members, and internal team to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.
About Blue Cross and Blue Shield of Nebraska
Blue Cross and Blue Shield of Nebraska is dedicated to championing the health and well-being of its members and the communities they serve.