Blue Cross and Blue Shield of Louisiana

Nurse

• Assess members’ status by collecting in-depth patient information and identifying needs
• Develop and implement comprehensive disease management plans with specific objectives, goals, and actions
• Implement interventions to accomplish established goals
• Coordinate, organize, integrate, and modify resources needed to accomplish goals
• Monitor plans by gathering information and evaluating effectiveness
• Meet staff and unit performance targets and department productivity goals
• Perform care coordination or Utilization Management as designated by RN and/or clinical leadership
• Research and interpret contract benefits to facilitate accurate benefit administration and product-specific authorization requirements
• Conduct medical necessity reviews using accepted criteria, guidelines, medical delegations, and policies
• Review, resolve, and respond to utilization-of-benefits issues and coordinate appropriate care
• Negotiate payment rates when provider network deficiencies exist
• Calculate and document care management savings, identify product enhancement opportunities, and capture ROI
• Communicate with members and providers regarding contract requirements and collect planned-care information by telephone
• Manage verbal notifications and written materials in compliance with regulatory and operational guidelines
• Serve as a technical resource to non-clinical staff by interpreting clinical information
• Perform other job-related duties within scope of responsibilities

Care Coordination Nurse I

Business Intelligence Analyst

• Gather data and prepare operational reports
• Introduce process improvements through the reporting process
• Enter data into existing databases
• Perform low-complexity modifications to databases
• Run standard reports
• Provide ad hoc reporting for business operations
• Monitor and send recurring reports for business areas
• Conduct basic-level testing
• Follow data-gathering best practices to ensure accurate and repeatable processes
• Modify existing reports based on changing business requirements
• Collect data for later analysis
• Monitor reporting environments for performance issues
• Collaborate with higher-level personnel on troubleshooting
• Review existing reports and validate the need for existing and new reports
• Perform other job-related duties within the scope of responsibilities
• Report to Departmental Leadership and liaise with departmental leadership and other BCBSLA divisions

Associate Operational Reporting, Data Analyst

Intake Coordinator

• Respond to provider requests telephonically and electronically for preauthorization of inpatient admissions and outpatient services and procedures
• Verify benefits, eligibility, and provider network status
• Promote and maintain a positive company image through telephonic and electronic contact with internal and external customers
• Meet staff and unit performance targets and departmental productivity goals
• Receive member clinical data, enter relevant case information, and follow departmental processes to authorize services
• Forward cases and clinical data to the appropriate Utilization Review team when approval is not allowed by process
• Manage authorizations to minimize healthcare disruption, standardize decision timeliness, and accommodate provider/member needs
• Manage verbal notifications and written materials in compliance with regulatory and operational guidelines
• Maintain knowledge of lines of business, laws and regulations, data exchange code sets, medical terminology, computer systems, Care Management and URAC policies and procedures
• Complete special assignments and projects requested by management
• Comply with laws and regulations associated with job duties
• Perform other job-related duties within the scope of responsibilities

Analyst

• Perform pricing and transparency reporting functions to support compliance with Blue Cross Association and federal mandates
• Provide members with cost information for common medical procedures, surgeries, treatments, and quality-of-care information
• Support facility and professional reimbursement areas through implementation of processes, procedures, reports, software, and operational refinements
• Collaborate with cross-divisional business areas, IT, and vendors to improve reimbursement operations and solve organizational information challenges
• Build an efficient, effective, and compliant technical analytical reporting infrastructure
• Refine, implement, automate, and manage the reimbursement operations strategy with senior team members and the Manager, Healthcare Price and Transparency
• Design, configure, implement, maintain, and document transparency cost algorithms for internal and external transparency initiatives
• Assess reimbursement operations, determine business requirements, identify improvement opportunities, and assist with business and technology systems design
• Recommend business process improvements, system testing, controls, and protocols
• Perform data transformation, data validation, reporting, and analytics

Healthcare Price & Transparency Analyst

Reviewer

• Conduct clinical reviews of behavioral health service requests, claims, and appeals
• Review pre-authorization requests, concurrent reviews, and retrospective behavioral health claims
• Apply InterQual and medical policy criteria to document medical necessity
• Refer cases not meeting criteria to the Psychiatric Medical Director for secondary review
• Support the appeals department in reviewing provider and member appeals within regulatory timelines
• Interact with behavioral health care providers regarding level-of-care and service decisions
• Document clinical decisions and rationale in the utilization management system
• Communicate determinations to providers and members by phone and written correspondence
• Analyze behavioral health member data to improve quality and appropriate service utilization
• Collaborate with Case Management, Quality, Provider Relations, and other internal departments
• Maintain compliance with CMS, NCQA, URAC, and other state, federal, and accreditation requirements
• Participate in audits, training, and quality-improvement initiatives
• Perform other job-related duties within the scope of responsibilities

Behavioral Health Utilization Reviewer

Call Center Representative

• Design, engineer, implement, administer, and optimize enterprise voice, contact center, and communication technology solutions
• Lead technical design and implementation of complex platform enhancements, integrations, and service improvements
• Develop technical designs, implementation approaches, standards, and support practices
• Evaluate, test, recommend, and implement new technologies, service enhancements, and AI-enabled solutions
• Lead complex troubleshooting, root-cause analysis, and service restoration for critical communication services
• Develop and maintain integrations between communication platforms, business applications, cloud services, and enterprise systems
• Design and implement automation solutions, scripts, utilities, workflows, APIs, and lightweight applications
• Monitor platform health, performance, availability, capacity, and security
• Lead or significantly contribute to upgrades, migrations, modernization, and technology transformation initiatives
• Develop technical documentation, operational procedures, design standards, and knowledge-sharing materials
• Provide technical mentoring, coaching, and knowledge transfer to engineers and support teams
• Support resiliency planning, disaster recovery readiness, and continuity-related testing
• Recommend process improvements, operational efficiencies, engineering best practices, and longer-term service improvements
• Perform other job-related duties as assigned

Senior Enterprise Voice, Contact Center Technology

Claims Specialist

• Research and verify complex claims information for accurate and timely claims processing
• Enter coded and other required information into claims systems
• Review and correct scanned claims documents
• Check claims for completeness and accuracy before final entry
• Identify and resolve inconsistencies and request missing information
• Ensure contract benefits are applied correctly
• Research procedural questions using supporting documentation and training manuals
• Identify incomplete adjudication instructions and suggest procedure updates
• Identify training issues and consult management when necessary
• Record daily production information including edits processed, hours worked, downtime, and special projects
• Reject, redirect, or return incomplete or inaccurate claims
• Maintain contact with internal departments, staff, providers, members, lawyers, insurers, and other external entities
• Perform other job-related duties within the scope of responsibilities

Claims Processor I

Strategy

• Perform as an autonomous and fully integrated member of the Corporate Strategy Office team
• Assist with research and data gathering, including secondary research, market trends, company priorities, vendor research, and Blue profiles
• Develop executive-ready presentations, briefings, and other compelling, visually driven communications
• Oversee collection and reporting of key performance indicators and metrics for the organization’s three-year strategic plan
• Participate in strategy discussions with senior management and cross-departmental teams
• Assist in creating and executing internal communications, including ideation, concept design, copywriting, script writing, and other design elements
• Administer and oversee the strategy home page
• Design, create, and deploy surveys, including tracking and sharing results
• Complete ad hoc projects as assigned

Corporate Strategy Intern

General

• Support mandated and risk-based audit activities through research, planning support, documentation, data analysis, and other assigned project work
• Maintain vendor and SOC report inventories and tracking tools
• Research vendors, regulatory requirements, industry standards, and emerging trends to support audit planning and vendor oversight
• Create training guides, reference materials, process documentation, and other knowledge management resources
• Support metrics, dashboards, and reporting initiatives
• Assist with the development and enhancement of Vendor Oversight and SOC program resources