Blue Cross and Blue Shield of Nebraska (BCBSNE) is more than just an insurance company; we exist to be there for people in the best and hardest moments of their lives.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it!

As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

This position leads, develops and manages the Service Medicare Advantage (MA) Team. The manager will provide leadership and execute decision-making based on subject matter expertise, meeting expectations with CMS and URAC guidelines and internal success measures. This position is responsible for solving problems, managing day-to-day and quickly adapting processes to meet performance requirements of the service team. The position will be responsible for closely working with internal partners in support of operations and the MA program. The incumbent is responsible for the oversight and operations of the dedicated service MA team which includes inbound/outbound service requirements, quality, training, grievance and appeals submitted for Medicare Advantage programs, not aligned to our utilization management team. The position will be responsible for closely aligning to our compliance team for delivery of all Centers for Medicare and Medicaid Services (CMS) guidelines.

BCBSNE is happy to offer four work designations for our Omaha area employees: 100% in-office, Hybrid options, and 100% remote. If choosing to work remote, this role can be located in one of the following states: Colorado, Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas.

What you'll do:

• Provide administrative and clinical guidance to dedicated MA service staff.

• Establish and maintain conformity with Medicare Advantage policies and procedures that ensure delivery of a strong program.

• Identify trends, patterns, and opportunities for improvement in service - delivering strong quality, satisfaction, and targeted cost.

• Communicate and collaborate with other departments to establish workflow processes.

• Conduct regular case audits, analyze results, and execute corrective action plans (CAP) to address any identified issues.

• Design and produce timely reports in compliance with state and federal technical specifications and internal requirements.

• Develop evidence and documents for external audit, to include Department of Insurance (DOI), Utilization Review Accreditation Commission (URAC) audits, submission to include updated workflows for grievances. Act as the escalation point for grievances received by the team.

To be considered for this position, you must have:

• Bachelor's degree in business, health care, or a related field.

• Five (5) years of related experience with three (3) years of management experience.

• Knowledge of Medicare Advantage service requirements.

An equivalent combination of education and experience may be substituted for this requirement.

The ability to meet or exceed the attendance and timeliness requirements of their departments.

The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.

The strongest candidates for this position will also possess:

• In-depth knowledge of process improvement strategies and techniques and an ability to apply analytical problem-solving skills.

• Well-developed written and verbal presentation skills.

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans