Remote Behavioral Health Utilization Review Jobs in Rhode Island

Pay Range:

Please emailHR_Talent_AcquisitionTeam@bcbsri.orgif you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI, our greatest resource is our people.

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do-not just for our members, but for our employees as well.

We recognize that to do your best work, you have to be your best self.
It's why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you're at in the organization, you're an integral part of our team and your input, thoughts, and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

We're dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state-building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Must be commutable distance to Providence, RI

Why this job matters:

Assist members in navigating the behavioral healthcare system, ensuring access to evidence-based care. Educate, empower, and coordinate services for members to improve their health and well-being. Facilitate communication between patient, provider, and health plan to ensure members receive the full benefit of integrated care.

What you will do:

• Manage members through the behavioral healthcare delivery system; assess needs in order to identify appropriate interventions.
• Conduct telephonic or face to face health assessments to identify high risk or emerging risk members who would benefit from education and intervention. Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the members' total health.
• Identify opportunities to impact claims expense trends for all lines of business/or at the individual member level.
• Evaluate action plans by working with members and collaborating with providers. Modify action plans as necessary.
• Monitor and evaluate patient services to ensure appropriate coordination of care. Collaborate with the Utilization Review process including pre-authorization, concurrent review, screening cases for quality-of-care issues, and discharge planning. .
• Promote member and provider satisfaction by demonstrating working knowledge of member benefits, including but not limited to health, disability, Employee Assistance, or other plans/benefits available to the member
• Provide continuity and consistency of care by building positive relationships between the member and family, physicians, provider, care coordinator, and health care plan.
• Work collaboratively with the team and others necessary to develop and implement solutions. Identify barriers to performing job duties as well as opportunities for improvements. Exemplifying the corporate values in action through accountability, collaboration, integrity, and respect in maintaining a high-performance culture.
• Participate in weekly on-site initiatives at local MH and SUD facilities.
• Participate in department initiatives and projects.
• Perform other duties as assigned.

What you need to succeed:

• Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC), or licensed psychologist (doctoral level), Licensed Mental Health Counselor (LMHC) or licensed independent clinical social worker (LICSW).
• Three to five years' experience in a medical/clinical environment or managed health plan
• Must obtain Certified Case Manager (CCM) certification within three years of employment*
• Knowledge of utilization management and/or coordination of care
• Knowledge of population health and chronic condition management principles
• Understanding of health care delivery system access points and services
• Ability to navigate the healthcare delivery system
• Good business acumen
• Knowledge of business process improvement techniques and strategies
• Excellent verbal, written communications and technical skills
• Negotiation skills
• Presentation skills
• Decision-making skills
• Good problem-solving skills
• Ability to interface with employees at all levels
• Ability to effectively navigate ambiguous situations with limited direction
• Excellent organizational skills and ability to successfully prioritize multiple tasks
• Ability to handle multiple priorities/projects
• Strong time management skills

*Applies to positions working with FEP product only

The extras:

• Experience working in a managed care/health maintenance organization
• Experience in specialties such as pediatrics, adolescents, and geriatrics.
• Knowledge of healthcare plans and benefits.

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
  

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity employer.

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