Arkansas Blue Cross Blue Shield

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.

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here. Job Summary The Manager of Virtualization Services manages, creates, implements, and supports the Virtualization infrastructure for the enterprise. In this role, the incumbent will be a champion to drive the transformation from a technology-centric organization to become an indispensable partner of the business by creating business value and responding rapidly to changing business requirements. Requirements EDUCATION Bachelors degree in computer science, management information systems, business or related field. In lieu of degree, five (5) years' technical experience with operations and procedures including configuring, tuning monitoring, securing, and managing a virtual infrastructure will be considered. CERTIFICATIONS & LICENSES None EXPERIENCE - Minimum seven (7) years’ Virtual infrastructure Design and Implementation, Project Management (SCRUM AGILE Framework), OR applicable Masters in related field with five (5) years’ above listed experience. - Minimum two (2) years’ leadership experience (role, project management, team, etc.) - Minimum two (2) years' technical Leadership experience managing Virtual Services Infrastructure Design, Implementation, and support teams. - In-depth knowledge of Virtualization technologies - Knowledge of traditional and cloud technology infrastructure - Knowledge of ITIL v4 or later framework. - Experience with a Blue Cross Blue Shield Plan, Commercial Carrier, Managed Care, or other health insurance related company preferred. ESSENTIAL SKILLS & ABILITIES - Coaching - Leading - Problem Solver - Compelling Communication - Continuous Learning - Creating a Culture of Trust - Customer Focus - Driving Execution - Driving Innovation Skills • Coaching • Coaching Others • Continued Learning • Cross-Functional Communications • Employee Engagement Strategies • Interpersonal Communication • Interpersonal Relationship Management • Interpersonal Relationships • Management Techniques • Service Oriented Responsibilities • Analyzes performance, availability, reliability and accuracy for each supported technology. Makes recommendations for improvements. • Assists identifying priorities and preparing resource requirements for each project or program. • Develops Disaster Recovery and Business Plans. • Ensures a consistent and effective change management process is used to migrate all IT infrastructure modifications to production environments. • Ensures adequate and timely reporting of the status of all active and scheduled projects and key performance indicators including SLAs. Generates and presents periodic management reports to appropriate committees and provide recommendations as to organizational changes or issues related to strategy by leveraging the project and portfolio management system. • Ensures development and sharing of best practices across all of IS&T to create an efficient organization. • Ensures that all infrastructure changes and additions are subjected to a thorough quality assurance process before migrating to production to improve quality the systems delivered to business. • Identifies opportunities for the appropriate and cost-effective investment of financial resources in IT systems and resources, including staffing, outsourcing, purchasing, and in-house development. • Implements and ensures adherence to information security office recommendations, ABCBS Security Incident Response Process and ABCBS Systems Security Plans. • Improves capacity utilization and eliminating unnecessary waste and overhead by removing duplication of effort, reducing rework, cross-training and repurposing resources by maximizing cross-platform synergies. • Manages, plans, and organizes staff in an efficient and effective manner to increase business agility, efficiency, customer centricity and support the business, vendors, partners, local and state government constituents. • Manages, supports, and maintains continuous delivery of day-to-day IT infrastructure services (“Keep the lights on”) through proactive monitoring and analysis of service level agreements and key performance indicators or metrics. • Manages the hiring, coaching/training, employee development and performance management of assigned team and performs data-driven performance evaluations. • Plans, organizes, and manages a competent staff in order to implement and maintain effective applications and processes within the team to meet enterprise, government, and customer priorities, objectives and commitments. 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 Pharmacy Technician works closely with Pharmacists under the Medicare area to ensure the health and safety of Arkansas BlueCross BlueShield members while helping to ensure the availability and cost efficiency of in-demand medications and prescriptions. The incumbent serves as primary operational support for the Medicare Pharmacy area. Requirements EDUCATION High school diploma or equivalent required. LICENSING/CERTIFICATION Certified Pharmacy Technician (CPhT) required from the Pharmacy Technician Certification Board (PTCB). EXPERIENCE & KNOWLEDGE Minimum five (5) years' experience in a pharmacy environment required. Knowledge of medications and common indications. Understanding of insurance claims, pharmacy benefit manager (PBM), and adjudication procedures preferred. ESSENTIAL ABILITIES Ability to accomplish tasks with limited supervision. Eagerness to research and learn Medicare law changes year over year. Skills • Customer Service • Documentations • Drug Information • Microsoft Office • Prioritization • Report Processing • Researching • Verbal Communications • Written Communication Responsibilities • Ensures that regulatory compliance and strict timelines are met, policies are carried out, and objectives are accomplished. • Participates in staff meetings to ensure appropriate information is reported and communicated. • Performs other duties as assigned. • Supports the Medicare Pharmacy Team with operational duties and tasks. • Troubleshoots, reports, and follows-up with findings from daily reports. Certifications Certified Pharmacy Technician (CPhT) - Pharmacy Technician Certification Board (PTCB) 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.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. 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 Responsibilities - 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 - 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. 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.

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here. Job Summary The Nutritionist Case Manager is accountable for promoting improved outcomes and member health through nutrition counseling. The RDN CM provides Medical Nutrition Therapy (MNT) counseling to members and/or caregivers, provides dietary care plans, nutritional health monitoring and coordinates educational resources for members. This includes education of members with Chronic Conditions (ex. Diabetes, Cancer, Heart Disease, Renal Disease) and long-term weight management issues. The incumbent will work collaboratively with other health disciplines and departments to optimize nutrition care and member experience. Requirements EDUCATION Bachelor’s degree in Nutrition and Dietetics with completion of an accredited Dietetic Internship or Coordinated Undergraduate Program in Dietetics. Master’s degree preferred. LICENSING/CERTIFICATION Registered Dietitian (RD) or Registered Dietitian Nutritionist (RDN) with current active state license with the Commission on Dietetic Registration/Academy of Nutrition and Dietetics in good standing in the state(s) where job duties are performed required. Certification required. If certification is not obtained prior to employment, must obtain URAC – recognized within three (3) years of hire as a case manager. Acceptable case management certifications are CCM, ACM, and RN-BC. Certified Diabetic Educator, Renal Nutrition, or other specialty certification preferred. EXPERIENCE Minimum four (4) years' clinical dietitian experience in healthcare setting, such as hospital, clinic, or home health. ESSENTIAL SKILLS & ABILITIES Excellent oral & 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 make sound judgements and decisions based on facts and guidelines. Ability to build collaborative relationships. Ability to interpret complex documentation. Ability to work independently with little supervision. Skills • Active Listening • Analytical Problem Solving • Business Compliance • Collaborative Communications • Consultative Approach • Counseling Services • Critical Thinking • Cross-Functional Communications • Cross-Functional Planning • Customer Relationship Management (CRM) • Data Analysis • Data Management • Documenting/Recording Information • Educational Development • Information Ordering • Microsoft Excel • Microsoft Office • Microsoft Outlook • Microsoft PowerPoint • Microsoft Word • Motivational Techniques • Oral Communications • Problem Sensitivity • Psychology • Researching • Service Oriented • Social Awareness • Sound Judgment • Speech Clarity • Support Coordination • Training and Development • Training Instruction • Written Communication Responsibilities • Collaborates with health team members to address barriers to meeting nutritional needs or goals. • Conducts preventative, therapeutic and general nutrition consultations telephonically with members and/or caregivers. Provides follow-up to ensure understanding and compliance with care plan. • Counsels member, family, and/or caregiver on prescribed nutrition therapy and monitors adherence and responses to therapy. • May also be required to assess/evaluate members receiving home tube feeding. • Participates in case management activities to include: ongoing assessment of health needs, individualized care plans, implementation, monitoring and evaluation of outcomes. • Screens, assesses and evaluates members’ nutritional needs and current health. Develops and implements dietary care plans and provides nutritional counseling. Certifications Certified Case Manager (CCM) - The Commission for Case Manager Certification (CCMC)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.