Arkansas Blue Cross Blue Shield

Role Description Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and/or other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence. Qualifications - Bachelor's degree in Nursing preferred. - Registered Nurse (RN) with active, current, unrestricted and recognized in the relevant jurisdiction, state license in good standing in the state(s) where job duties are performed required. - Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing. - Experience in utilization management and/or medical review preferred. Requirements - Oral & Written Communication - Attention to Detail - Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding. - Ability to prioritize and make sound nursing judgments through critical thinking. - Ability to build collaborative relationships. - Ability to interpret complex documentation. - Ability to work independently. - Active Listening - Analytical Decision Making - Critical Thinking - Data Analysis - Educational Development - Interpersonal Relationship Management - Microsoft Outlook - Microsoft SharePoint - Microsoft Word - Oral Communications - Problem Sensitivity - Sound Judgment - Team Development - Time Management - Written Communication Benefits - Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels. - Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards. - Performs other duties as assigned. - Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety. - Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence. - Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts. - Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively. Certifications - This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. - Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type Regular ADA Requirements 2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.

Role Description The Membership Enrollment Specialist I processes enrollment additions, updates, changes, reinstatements, and terminations in an accurate and timely manner for the assigned product line. The incumbent is responsible for processing of renewals and premium billing. The incumbent works closely and directly interacts with external customers such as employer groups, 834 vendors and brokers/consultants, and with internal customers such as Underwriting, Account Management, Sales, Customer Service staff, Claims staff, etc. to answer questions and resolve issues. Qualifications - High School diploma or equivalent. - Minimum two (2) years' college coursework (48 semester hours) or other equivalent certification with an emphasis in general business, health plan administration, or medical-related fields of study OR minimum of one (1) year of relevant office work experience (such as claims administration, medical office, health insurance, etc.). Requirements - Strong time management and organizational skills - Results-driven with highly developed attention to detail - Primary focus on accuracy and outcomes - Customer service - Strong interpersonal skills - Keyboarding - Dependability - High integrity - Confidentiality - Problem solving - Issue resolution - Sound judgment - Computer literacy - Microsoft Office - Oral and written communication - Teamwork Responsibilities - Accepts, investigates, and responds to incoming calls, e-mails, and other forms of communication in an accurate, timely and professional manner. - Assists with employer groups, 834 vendors, brokers/consultants, Customer Service, Claims, Account Management and/or Sales staff needs, as required. - Confirms information including but not limited to: enrollment/membership status, records, questions or concerns, and database requests. - Drives and supports high-work-volume Open Enrollment activities each year. - Generates and distributes membership-related documents such as ID cards, Certificates of Coverage, Certificates of Creditable Coverage, etc. - Maintains ongoing correspondence with internal and external customers. - Performs other duties as assigned. - Processes enrollment additions, changes, reinstatements, and cancellations in an accurate and timely manner. - Provides clerical and technical support for enrolling members, membership vendors, brokers and consultants, and employer groups. - Provides excellent customer service and guidance to both internal and external customers. - Responsible and accountable for up-to-date knowledge and achievement of divisional standards related to production, quality, and dependability. Certifications - This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. - Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type - Regular ADA Requirements - 1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.

Role Description The RN Case Manager plays a critical role in optimizing patient care and resource utilization. The incumbent is responsible for: - Assessing, planning, implementing, coordinating, monitoring, and evaluating comprehensive care plans to meet individual health needs. - Focusing on quality patient outcomes and cost-effective healthcare delivery. - May encompass general medical case management or specialize in high-acuity areas and/or high-cost areas such as: - High-risk obstetrics and neonatal care - Chronic disease management - Mental health support (excludes Behavioral Health) Qualifications - Bachelor's degree in Nursing preferred. - Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required. - Case management certification required. If certification is not obtained prior to employment, must obtain URAC recognized within three (3) years of hire as a RN Case Manager. Acceptable case management certifications include: - Certified Case Manager (CCM) - Accredited Case Manager (ACM) - Registered Nurse - Board Certified (RN-BC) - Minimum four (4) years' clinical practice experience in at least one of the following areas: - Case management - Home health - Critical care - Medical/surgical - Discharge planning - Concurrent review - Obstetric/neonatal care Requirements - Independence - Detail oriented - Skills: - Administrative Process - Affinite CM - Affinite UM - CCI Edits - Collaborative Communications - Critical Reasoning - Cross-Functional Planning - Customer Relationship Management (CRM) - Customer Service - Workstation - Deductive Reasoning - Five9 - Information Security - Interpersonal Relationship Management - Microsoft Excel - Microsoft Office - Microsoft Outlook - Microsoft PowerPoint - Needs Assessment - Oral Communications - Problem Sensitivity - Researching - Sound Judgment - Support Coordination - Written Communication Responsibilities - Assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet an individual’s health needs through the use of plan benefits and community resources to facilitate appropriate cost effectiveness and cost containment measures. - Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards, and individual state regulations. - Provides specialized education and knowledge on disease-specific conditions as needed and assigned. - Remains current with up-to-date medical and surgical procedures, products, healthcare services, and drugs, as well as general trends in healthcare delivery. - Serves as a liaison facilitating a collaborative process which includes patients, families/caregivers, physicians, hospital discharge planners, home care providers, and other ancillary providers. - Works proactively with referrals from multiple sources to identify appropriate candidates for case management, explains services ensuring voluntary agreement of services, and maintains a minimum patient caseload in a timely manner. Certifications - Accredited Case Manager (ACM) - American Case Management Association (ACMA) - Certified Case Manager (CCM) - The Commission for Case Manager Certification (CCMC) - Registered Nurse (RN) - Arkansas State Board of Nursing Security Requirements This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. Employment Type Regular ADA Requirements 2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of the location of primary work assignment as essential functions of the job.

Role Description The Developer Senior is responsible for developing, documenting, educating and articulating moderately complex business requirements to support enterprise business solutions initiatives, ranging from vision to implementation, strategy, development and tactical execution of objectives. Incumbent will also contribute expertise in system analysis, design, coding, testing, debugging and documenting the development of all lifecycle phases. Qualifications - Bachelor’s degree in Business, Computer Science, Management Information Systems, or related field. - In lieu of Bachelor's degree, completion of an Associate's degree OR 72 hours credit toward a Bachelor's degree in a relevant technical field plus three (3) years of relevant experience will be considered. Requirements - Minimum five (5) years' direct experience serving source systems and project teams for developing, documenting, educating and articulating moderately complex business requirements. - Knowledge and experience with data gathering, program logic development, coding, testing and documentation. - Experience in Application Systems Programming Design and Analysis. - Experience as a Programming Lead in at least one (1) large-scale project. Essential Abilities - Active Listening - Oral Communications - Ab Initio - Written Comprehension - Coaching - Oral Comprehension - IBM InfoSphere DataStage - Structured Query Language (SQL) - Written Expression - Problem Solving - Time Sharing - JavaScript - RedHat Enterprise Server - Unix - Developing Other - Interpersonal Communication Skills - Ab Initio - Active Listening - Analytical Problem Solving - Apache Kafka - API Development - Bash (Scripting Language) - Coaching - Collaborative Communications - GitHub - IBM InfoSphere DataStage - IBM InfoSphere MDM - IBM Rational Application Developer (RAD) - IBM WebSphere Application Server - JavaScript - Linux - Mobile Device Management (MDM) - Oral Communications - Red Hat Enterprise Linux (RHEL) - Structured Query Language (SQL) - Time Sharing - Unix Operating Systems - Waterfall Model - Written Communication Responsibilities - Consults with users to identify current operating procedures and to clarify project objectives. - Contributes to and supports the Enterprise business solutions strategic and operational planning process. - Designs, testable code and develops test protocols or plans and reviews revisions and results. - Designs and develops high-volume, low-latency applications for mission-critical systems. - Develops and implements processes to ensure accurate and effective workflow distribution. - Develops applications as defined in requirements and business solutions. - Enhances and applies programming skills to include analysis, design, coding, testing, debugging, implementation and documentation. - Provides technical expertise of subsystems and any other performance related systems. - Uses standard application design principles to create appropriate logical and physical application designs. Security Requirements This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. Employment Type Regular ADA Requirements 1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.

Role Description The RN Case Manager plays a critical role in optimizing patient care and resource utilization. The incumbent is responsible for: - Assessing, planning, implementing, coordinating, monitoring, and evaluating comprehensive care plans to meet individual health needs. - Focusing on quality patient outcomes and cost-effective healthcare delivery. - Encompassing general medical case management or specializing in high-acuity areas and/or high-cost areas such as: - High-risk obstetrics and neonatal care - Chronic disease management - Mental health support (excludes Behavioral Health) Qualifications - Bachelor's degree in Nursing preferred. - Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required. - Case management certification required. If certification is not obtained prior to employment, must obtain URAC recognized within three (3) years of hire as a RN Case Manager. Acceptable case management certifications include: - Certified Case Manager (CCM) - Accredited Case Manager (ACM) - Registered Nurse - Board Certified (RN-BC) - Minimum four (4) years' clinical practice experience in at least one of the following areas: - Case management - Home health - Critical care - Medical/surgical - Discharge planning - Concurrent review - Obstetric/neonatal care Requirements - Independence - Detail oriented - Administrative Process - Affinite CM - Affinite UM - CCI Edits - Collaborative Communications - Critical Reasoning - Cross-Functional Planning - Customer Relationship Management (CRM) - Customer Service - Deductive Reasoning - Five9 - Information Security - Interpersonal Relationship Management - Microsoft Excel - Microsoft Office - Microsoft Outlook - Microsoft PowerPoint - Needs Assessment - Oral Communications - Problem Sensitivity - Researching - Sound Judgment - Support Coordination - Written Communication Responsibilities - Assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet an individual’s health needs through the use of plan benefits and community resources to facilitate appropriate cost effectiveness and cost containment measures. - Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards, and individual state regulations. - Provides specialized education and knowledge on disease-specific conditions as needed and assigned. - Remains current with up-to-date medical and surgical procedures, products, healthcare services, and drugs. - Serves as a liaison facilitating a collaborative process which includes patients, families/caregivers, physicians, hospital discharge planners, home care providers, and other ancillary providers. - Works proactively with referrals from multiple sources to identify appropriate candidates for case management. Certifications - Accredited Case Manager (ACM) - American Case Management Association (ACMA) - Certified Case Manager (CCM) - The Commission for Case Manager Certification (CCMC) - Registered Nurse (RN) - Arkansas State Board of Nursing Security Requirements This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. Employment Type Regular ADA Requirements General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of the location of primary work assignment as essential functions of the job.

Role Description The member triage nurse assesses members for needed resources such as community resources, vendor assistance, case management services, and other interdisciplinary services associated with Clinical Services and Population Health division (CSPH). This position is responsible for answering and routing calls to support the CSPH division, including warm transfers to/from customer service, case management, other support services and resources as appropriate. This position is also responsible for promoting communication through any other omni channels available such as mobile applications. Qualifications - Bachelor's degree in Nursing preferred. - Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required. - Case Management certification preferred. - Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing. Requirements - Excellent oral and written communication skills - Detail-Oriented - Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding. - Ability to prioritize and make sound nursing judgments through critical thinking. - Ability to build collaborative relationships. - Ability to interpret complex documentation. - Ability to work independently with little supervision. Skills - Active Listening - Analytical Decision Making - Business Compliance - Collaborative Communications - Conflict Resolution Management - Coordinating Resources - Critical Thinking - Cross-Functional Communications - Cross-Functional Planning - Data Management - Information Interpretation - Interpersonal Relationship Management - Microsoft Excel - Microsoft Outlook - Microsoft PowerPoint - Microsoft Word - Oral Communications - Problem Sensitivity - Public Relations (PR) - Researching - Service Oriented - Support Coordination - Time Management - Written Communication Responsibilities - Communication: Serves as a liaison facilitating a collaborative process which includes patients, families/caregivers, physicians, hospital discharger planners, home care providers and other ancillary providers to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels. - Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety. - Knowledge: Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts. - Member Triage: Assesses and resolves gaps in patient care related to chronic health conditions through health education and case management services ensuring gaps are closed in a timely manner. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence. - Performs other duties as assigned. - Workflow: Works proactively with referrals from multiple sources to identify gaps in care candidates for case management, explaining services ensuring voluntary agreement of services and maintaining a minimum patient caseload in a timely manner. Certifications This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type Regular ADA Requirements 2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.

Role Description The Systems Administrator Senior installs and maintains operating systems and related software and/or administers activities for mainframe operating system, ensuring & achieving high performance of these systems. Qualifications - Bachelor’s degree in Business, Computer Science, Management Information Systems, or related field. In lieu of degree, at least five (5) years of equivalent experience will be considered. - Minimum five (5) years’ direct experience with server support and implementation to include maintaining and supporting open systems, operating systems and client server-based applications. - Experience as a lead in at least one (1) large-scale project. - Comprehensive knowledge and experience with operations and procedures including configuring, tuning, monitoring, securing, and managing server software and hardware. - Comprehensive knowledge of shell and kernel-level programming and system-specific requirements. Requirements - Shell Programming - Kernel-level programming - Microsoft Windows - Analytical Problem Solver - Troubleshooting - Red Hat Linux System Administration - TCPIP Protocols - Domain Name System (DNS) - Storage Virtualization - Disaster Recovery - Project Management - Technical Expertise - Detail-Oriented - Interpersonal - Leadership - Multitasking - Oral & Written Communications - Technical Communication - Configuration Management (CM) - Continued Learning - Directory Services - Disaster Recovery (DR) - Documentation Maintenance - Linux Server Administration - Office Softwares - Oral Communications - Scripting - Server Backups - Technical Project Management - Vulnerability Management - Web Server Administration - Windows Server Management - Written Communication Responsibilities - Analyzes and evaluates user requests for server and technical operations, services, and support. - Assists other department teams with IT server management functions including configuration, operations, installation, maintenance, and performance tuning of all server hardware and software. - Develops comprehensive policy and procedure documents for the open systems server infrastructure. - Monitors daily performance of systems and informs management of the status of the systems relative to previously established performance guidelines. - Performs technical duties assigned, as a member of department team(s), to enhance function and availability of the open system server environment. - Possesses knowledge of the strategic planning process in order to effectively maintain successful server management processes consistent with goals and objectives. - Provides leadership, coaching, and/or mentoring to subordinate groups and may act as a lead or first-level supervisor. - Researches and implements server components including software, hardware, security, administration, policies, and procedures. - Updates reporting mechanisms based on progression of projects. Certifications This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type Regular ADA Requirements 1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.

Role Description The Claims Specialist resolves medical claims that are not automatically adjudicated by the claims processing system in a timely and accurate manner according to divisional standards of quality and productivity. Resolution may include additional investigation or communication in order to obtain necessary information to complete the claim. Outside issues such as peak filing season, systems down time, inclement weather, holidays, and absenteeism may directly affect the volume of work for each Specialist. Qualifications - High School diploma or equivalent. - Minimum two (2) years' college coursework (48 semester hours) or other equivalent certification with an emphasis in anatomy, medical terminology, math, biology, or a related field. - OR minimum one (1) year of related office experience such as claims processing, health insurance, or medical office. - Must pass company proficiency test: Claims Assessment. Requirements - Oral & Written Communications - Strong Interpersonal skills - Sound Judgement - Decision Making - Detail-Oriented - Teamwork - Dependability - Clinical Judgment - Computer Work - Critical Thinking - Customer Service - Evaluating Information - Interpersonal Communication - Oral Communications - Organizing - Process Information - Reading Comprehension - Researching - Time Management Responsibilities - Claims Processing: Involves the actions required to pay or deny pended claims (those which did not auto-adjudicate), including: - Entering data into the system - Reviewing and interpreting contract benefits - Conducting edit and audit resolution - Determining benefit eligibility - Identifying and researching processing issues through systems and manuals - Routing claims to other areas - Consulting internal staff and medical providers - Generating correspondence - Completing forms to obtain necessary information - Knowledge/Continuous Learning: Must undergo initial training, on-the-job training, and continuing education. Responsibilities include: - Demonstrating knowledge of and possessing the ability to access all relevant computer systems and screens to process claims accurately - Staying current with continually changing processing procedures, benefits, and system modifications - Meeting corporate and national (MTM) standards while maintaining acceptable performance levels based on established departmental standards for productivity and quality - Familiarity with corporate and professional manuals and guidebooks, including the company processing manual and ICD, CPT, and HCPS codebooks - Other duties: As assigned Certifications This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type Regular ADA Requirements 1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here. Job Summary The Medical Director is responsible for contributing professional and technical expertise to the operation of the custom care management program. This includes the clinical aspects involved in the execution of the program and the planning, development and implementation of for program enhancements, membership expansion as well as the development and execution of any future services. Requirements EDUCATION Doctorate Degree in allopathic or osteopathic medicine required. LICENSING/CERTIFICATION Holds an active and current unrestricted license pertinent to the role and responsibilities in required jurisdictions. This position operates within the scope that permits them to apply their clinical judgement to render a utilization review determination. Active and current board certification in area(s) of specialty required. EXPERIENCE Minimum ten (10) years' active medical practice preferred. Minimum five (5) years' clinical leadership experience (role, team and/or project management) preferred. ESSENTIAL SKILLS & ABILITIES Proven ability to develop and implement strategic care initiatives. Ability to work and build relationships across multiple functions. Skills • Coaching Others • Consultative Approach • Continued Learning • Cross-Functional Communications • Decision Making • Deductive Reasoning • Employee Engagement Strategies • Evaluating Information • External Collaboration • Inductive Reasoning • Interpersonal Communication • Interpersonal Relationships • Management Techniques • Problem Solving • Process Information • Reading Comprehension • Researching • Service Oriented • Work Schedules • Writing Responsibilities • Collaborates closely with the Director of Care Management and Nurse Managers to ensure the effective delivery of custom care management. • Conducts presentations to Enterprise accounts as needed, pertaining to medical management, and provide clinical reporting or analysis as required to support Enterprise account business. • Directs the hiring, coaching/training, employee development and performance management of assigned team. • Facilitates problem resolution for Enterprise accounts. • Maintains availability for and pro-active in arranging peer-to-peer discussions with providers and facilities nationally and internationally in order to effectively manage appropriate care for Enterprise account members. • Participates in the appeals process at the first or second level in accordance with regulatory requirements and Enterprise account contracts along with organization determination as requested by outside providers. • Participates in the development of primary coverage criterial through selected reviews, presentations, and discussions of the evidence basis for medical science. • Performs other professional duties and responsibilities as assigned. • Possesses or develops and maintains a current in-depth understanding of the evidence-based clinical guidelines and treatments for the medical or behavioral health conditions within their scope and certification to render a clinical opinion or utilization review determination. • Provides consultation to care managers promptly and work with all team members in the custom care management model. • Reviews medical records as required to assist in utilization review activities pertaining the Enterprise. • Works closely with the Corporate Medical Directors, account managers and executives to ensure the smooth running of the accounts. • Works with vendors as needed such as Behavioral Health, Pharmacy, High Tech Radiology, etc. Certifications Security Requirements This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type Regular ADA Requirements 1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here. Job Summary The RN Case Manager plays a critical role in optimizing patient care and resource utilization. The incumbent is responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating comprehensive care plans to meet individual health needs. This role focuses on quality patient outcomes and cost-effective healthcare delivery and may encompass general medical case management or specialize in high-acuity areas and/or high-cost areas such as high-risk obstetrics and neonatal care, chronic disease management, and/or mental health support (excludes Behavioral Health). Requirements EDUCATION Bachelor's degree in Nursing preferred. LICENSING/CERTIFICATION Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required. Case management certification required. If certification is not obtained prior to employment, must obtain URAC recognized within three (3) years of hire as a RN Case Manager. The acceptable case management certifications are Certified Case Manager (CCM), Accredited Case Manager (ACM), and Registered Nurse - Board Certified (RN-BC). KNOWLEDGE & EXPERIENCE Minimum four (4) years' clinical practice experience in at least one of the following areas: case management, home health, critical care, medical/surgical, discharge planning, concurrent review, or obstetric/neonatal care. ESSENTIAL ABILITIES & SKILLS Independence Detail oriented Skills • Administrative Process • Affinite CM • Affinite UM • CCI Edits • Collaborative Communications • Critical Reasoning • Cross-Functional Planning • Customer Relationship Management (CRM) • Customer Service Workstation • Deductive Reasoning • Five9 • Information Security • Interpersonal Relationship Management • Microsoft Excel • Microsoft Office • Microsoft Outlook • Microsoft PowerPoint • Needs Assessment • Oral Communications • Problem Sensitivity • Researching • Sound Judgment • Support Coordination • Written Communication Responsibilities • Assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet an individual’s health needs through the use of plan benefits and community resources to facilitate appropriate cost effectiveness and cost containment measures are met. • Other duties as assigned. • Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations and makes decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety. • Provides specialized education and knowledge on disease specific conditions as needed and assigned. • Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery, enterprise procedures, policies and contracts. • Serves as a liaison facilitating a collaborate process which includes patients, families/caregivers, physicians, hospital discharger planners, home care providers and other ancillary providers to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels. • Works proactively with referrals from multiple sources to identify appropriate candidates for case management, explains services ensuring voluntary agreement of services and maintains a minimum patient caseload in a timely matter. Certifications Accredited Case Manager (ACM) - American Case Management Association (ACMA), Certified Case Manager (CCM) - The Commission for Case Manager Certification (CCMC), Registered Nurse (RN) - Arkansas State Board of NursingArkansas State Board of Nursing Security Requirements This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type Regular ADA Requirements 2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.