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Blue Cross Blue Shield of Michigan Senior Analyst / Utilization Review in Detroit, Michigan

Description

Responsible for leading the development and implementation of programs and strategies by identifying insights that enhance business decision making capability. This includes developing or changing workflows and implementing process improvements to enhance organizational products, programs and service to our customers.

  • Identify and analyze operational data and develop insights in support of business objectives.
  • Develop and improve work flows and business processes within defined areas to improve customer service, decrease operational costs and improve overall quality.
  • Identify and/or analyze business problems and develop recommendations for solutions to problems.
  • Lead the development and implementation of projects and/or teams in order to produce desired results.
  • Document and communicate project concepts, milestones and results.
  • Recommend and assist with implementing standard policies and procedures.
  • Ensure that corporate compliance is communicated, implemented and monitored on an ongoing basis.
  • Participate in systems testing, develop procedures/controls and provide recommendations for the ongoing improvement of the updated process.
  • Provide support to internal departments and external entities by answering questions, supplying information and training.
  • Create and present reports and presentations to display operational data and proposed business changes.

Departmental Summary / Preferences:

Manage contracted Medical Consultants

  • Set up and maintain Medical Consultant contracts

  • Ensure hourly rates remain in line as appropriate

  • Create PO’s, monitor balances and replenish as needed

  • Request system access as appropriate

  • Arrange training as appropriate

  • Ensure current licenses and Board Certification as appropriate

  • Ensure Compliance Training, Security Attestations, etc. completed

  • Summarize billed hours per consultant monthly and forward to A/P

  • Keep track of Consultant availability

  • Be readily available to offer assistance to Consultants

  • Accept calls from departments asking for specific specialty Consultant assistance on cases and make the introduction. (CFI, BCN, Medical Affairs, Network Management, Provider Communications, Provider Outreach, etc)

  • Notify the Sr. Medical Director of Med Consultant specialties needed.

Coordinate case reviews

  • Audit and CFI

  • Private Duty Nursing

  • eviCore appeals for Pain Management

  • PPUR

  • Liaison between Director Quality and Provider Education, Accumulator Team and Med Consultants for PPUR issues

  • Review decision write-ups as appropriate for quality

Other

  • Review and approve Blue Access requests submitted for Med Director-UM department staff

  • Delegated to do Blue Access attestations on behalf of Sr. Medical Direct

  • Assist Sr Medical Director with data requests (including collating and analyzing information)

  • Assist with developing reports using Excel and preparing PowerPoint presentations

  • Work closely with the Sr. Medical Director/Admin Assistant of UM department to provide additional support to UM department

  • Other duties as assigned

Clinical background (RN) is preferred.

Qualifications
  • Bachelor's Degree in a related field is preferred.
  • Four (4) years of experience in a related field is required.
  • Excellent analytical and problem-solving skills to identify, evaluate, recommend and implement changes to processes or procedures to address problems and improve departmental effectiveness.
  • Organizational skills and ability to prioritize; must be able to lead multiple activities with varying timelines.
  • Excellent verbal, written communication and interpersonal skills.
  • Ability to lead and contribute to business unit and/or corporate projects.
  • Proficient in Microsoft Office Suites.
  • Ability to develop and maintain effective working relationships.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

Job: Health Care Management

Primary Location: Detroit

Organization: BCBSM VP Hlth&Cln Aff& BCN CMO-2150

Schedule: Full-time

Req ID: MED0005Y

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