At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.
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.
What you'll do:
Conduct audits and reviews of clinical or utilization management documentation to ensure accuracy, completeness, and compliance with applicable standards and governing regulations (e.g., CMS, Accreditation, etc.).
Present findings and recommendations to leadership and collaborate on corrective actions (e.g., Plans of Correction - POCs).
Support the resolution of members or client appeals and grievances, providing clinical insight and documentation support, as assigned.
Develop and implement plans for improvement in response to audit findings or identified opportunities.
Educate and train staff, sales, physicians, specialists, etc. on documentation standards, regulatory requirements, and best practices; act as a subject matter expert (SME).
Collaborate with internal and external stakeholders to support readiness for audits and continuous quality improvement.
Lead or participate in initiatives to improve clinical or utilization management documentation and operational efficiency, based on area of assignment.
Analyze data to identify trends, gaps, and opportunities for improvement in clinical or utilization management processes.
Screen and triage individuals to determine appropriate levels and types of advocacy or management programs, as applicable.
Serve as a resource within the department and across other departments regarding clinical or utilization management issues.
Act as a clinical resource for teams such as sales, client relations, or others, as assigned.
Assist in presentations and reviews to communicate clinical data, trends, and outcomes.
Propose strategies for improving outcomes and containing costs.
To be considered for this position, you must have:
Associate's degree in nursing
Must possess a current, unrestricted Registered Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates.
Five (5) years of clinical nursing practice experience.
Three (3) years of experience in case management, discharge planning, utilization management, or disease management
Knowledge of accreditation standards and regulatory requirements (e.g., CMS Manual, NCDs/LCDs, NCQA standards, etc.)
Strong analytical skills and familiarity with healthcare cost analysis
Excellent communication, analytical, and collaboration abilities
Ability to educate and train clinical staff on documentation and compliance procedures
If assigned to Medicare Advantage Utilization Management team must also possess: Minimum of (2) years of Medicare Advantage Utilization Management and strong understanding of CMS regulations and accreditation standards.
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:
Bachelor's degree in the healthcare field.
Clinical experience across multiple levels of care (e.g., inpatient, outpatient, post-acute)
Experience conducting audits and writing corrective action plans.
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 Blue Shield of Nebraska
Oct 15, 2025