Blue Cross and Blue Shield of Nebraska

Pharmacist

• Create and Maintain Clinical Criteria for applicable Utilization Management (UM) programs: Develop and maintain clinical criteria (access to Prime standard and BCBSNE specific versions); Develop and maintain criteria process flows; Develop and maintain physician fax forms and other modes of communication; Utilize predictive modeling tool to intervene with high-risk members for identified disease states; Provide clinical updates as necessary to internal staff and physician reviewers; Performs highly complex research, analysis and develops recommendations for UM programs & plan design changes.
• Responsible for Operational workflows and Completion of UM reviews: Clinical oversight of first level review process; Clinical review of utilization management reviews; Perform clinical support for Pharmacy Technician and other staff; Utilize reporting tools to create efficiencies by reviewing medical and pharmacy claims data; Support physician reviewers with information required to efficiently review non-approvable claims; Develop Decision Tree review process when applicable.
• Maintain URAC accreditation: Work with internal staff to ensure that URAC accreditation is maintained; The pharmacist will work within their scope of licensure and unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting drug utilization review. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management, if prohibited by state utilization management laws. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management if the requesting party specifically requests a clinical peer.
• Measure quality assurance reporting, turnaround time for urgent and non-urgent reviews and quantitative assessment of UM reviews by program.
• Support Medicare Advantage processes, outreach, presentations, and tasks that require clinical direction and support. This includes, but not limited to, clinical presentations to internal and external stakeholders, providers, provider offices, and other customers.

Clinical Pharmacist

Data Analyst

• Analyze healthcare claims, pharmacy, lab, and Risk Adjustment submissions data to evaluate intervention and program performance.
• Develop, maintain, and present reports that measure intervention ROI, incremental conditions captured, risk score impact, revenue impact, and other key Risk Adjustment performance metrics.
• Partners with internal teams to support Risk Adjustment analytics needs, intervention planning, reporting enhancements, and issue resolution.
• Stay current on healthcare analytics, Risk Adjustment trends, tools, methodologies, and regulatory considerations; recommend process or reporting improvements where appropriate.
• Provide analytic solutions on ad-hoc requests with little oversight by senior analysts.

Risk Adjustment Data Analyst

Project Manager

• Lead the development, interpretation, maintenance, and ongoing evaluation of medical policies using evidence-based clinical literature, national guidelines, regulatory requirements, and coding updates
• Analyze emerging technologies, new procedures, pharmaceuticals, and clinical treatments to determine policy implications and organizational impact
• Serve as the clinical authority for complex medical policy interpretation and implementation
• Recommend policy revisions that improve consistency, quality, compliance, and operational efficiency
• Lead evaluation and implementation of ICD-10, CPT, HCPCS, NCCI, CMS, and other industry coding updates impacting claims adjudication
• Provide strategic oversight for coding edits and clinical business rules within HealthRules and other claims administration systems
• Partner with Configuration and IT teams to translate clinical requirements into system functionality
• Identify opportunities to improve automation, reduce manual intervention, and strengthen payment accuracy
• Lead enterprise-wide initiatives involving medical policy, payment integrity, claims modernization, and regulatory compliance
• Provide expert consultation to executive leadership and business partners regarding complex clinical policy issues
• Serve as the clinical liaison across operational, technical, and vendor teams during implementation of strategic initiatives
• Evaluate business impacts and recommend solutions that balance clinical appropriateness, member experience, provider relationships, and operational effectiveness
• Direct clinical validation, user acceptance testing, and end-to-end testing activities for policy and configuration changes
• Ensure policy implementations are accurate, compliant, and operationally effective prior to production deployment
• Monitor implementation outcomes and identify opportunities for continuous improvement
• Mentor analysts and other team members on medical policy interpretation, coding methodologies, and clinical best practices
• Build collaborative partnerships across internal departments and external vendors

Clinical Pharmacist

Risk Adjustment Data Analyst

Medical Policy & Special Project Clinical Analyst – RN