Care Manager PreService & Retrospective Job

About Blue Cross



At Blue Cross and Blue Shield of Minnesota, we are developing industry-leading strategies every day that make a healthy difference in people’s lives. Blue Cross has a legacy of improving health through innovation because we believe that everyone should have the opportunity to live the healthiest life possible. Chartered in 1933 as the state’s first health plan, we’ve been serving the health care needs of Minnesotans for more than 80 years.



Blue Cross supports you with competitive pay and a comprehensive benefits package. Many Employee Resource Groups are active in the company, promoting inclusion and helping us meet the diverse needs of our workforce and our members. Join us, and enjoy a work environment where all employees are respected and valued — a workplace honored with a perfect score on the Human Rights Campaign Corporate Equality Index for 2017. Find your place at a company that cares.



 


Description Summary

This job implements effective utilization management strategies including:  review of appropriateness of pre and post service health care services, application of criteria to ensure appropriate resource utilization, identification of referrals to a Health Coach/case management, and identification and resolution of quality issues.  Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives. Retrospective clinicians also evaluate appropriateness of code submission on facility and professional claims and complete unspecified code and modifier code reviews.


Accountabilities


  1. Applies clinical experience, health plan benefit structure and claims payment knowledge to pre- service and retrospective reviews by gathering relevant and comprehensive clinical data through multiple sources.

  2. Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.

  3. Completes review of both medical documentation and claims data to assure appropriate resource utilization, identification of opportunities for Case Management, identify issues which can be used for education of network providers, identification and resolution of quality issues and inappropriate claim submission

  4. Maintains outstanding level of service at all points of contact (e.g. members, providers, contract accounts).

  5. Maintains confidentiality of member and case information by following corporate and divisional privacy policies.

  6. Accountable for timely and comprehensive review of clinical data with concise documentation, decisions and rationale, according to regulatory standards and procedures.

  7. Recognizes and raises any trends and emerging issues to management and recommends best practices for workflow improvement.

  8. Mentors, coaches and fulfills the role of preceptor.

  9. Demonstrates the ability to handle complex and sensitive issues with skill and expertise. Accepts responsibility for and independently completes special projects or reports as assigned. Demonstrates competency in all areas of accountability.

  10. Establishes and maintains excellent communication and positive working relationships with all internal and external stakeholders.

  11. Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.

  12. Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member.

  13. Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.

  14. Reviews and identifies issues related to professional and facility provider claims data including determining appropriateness of code submission, analysis of the claim rejection and the proper action to complete the retrospective review with the goal of proper and timely payment to provider and member satisfaction.

  15. Identifies potential discrepancies in provider billing practices and intervenes for resolution and education with Provider Relations, or if necessary involve Special Investigation Unit.

  16. Monitors and analyzes the delivery of health care services in accordance with claims submitted, and analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction.


Requirements


  • Registered nurse with current MN license or licensed behavioral health clinician without restrictions or pending restrictions. 

  • 3 years of related, progressive clinical experience (i.e. RN or LPN to RN mix).

  • Demonstrated ability to research, analyze, problem solve and resolve complex issues.

  • Demonstrated strong organizational skills with ability to manage priorities and change.

  • Proficient in multiple PC based software applications and systems.

  • Demonstrated ability to work independently and in a team environment.

  • Adaptable and flexible with the ability to meet deadlines.

  • Able to negotiate resolve or redirect, when appropriate, issues pertaining to differences in expectations of coverage, eligibility and appropriateness of treatment conditions.

  • Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards and member contracts inorder to ensure compliance.


Preferred Requirements


  • 5 years of RN or relevant clinical experience.

  • 1+ years of managed care experience (e.g. case management, utilization management and/or auditing experience).

  • Bachelor’s degree in nursing.

  • Certification in utilization management or a related field.

  • Experience in UM/CM/QA/Managed Care.

  • Knowledge of state and/or federal regulatory policies and/or provider agreements, and a variety of health plan products.

  • Coding experience (e.g. ICD-10, HCPCS, and CPT).


FLSA Status

Exempt


Blue Cross Blue Shield of Minnesota is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Make a difference



Thank you for your interest in Blue Cross. Be part of a company that lets you be you — and make a healthy difference in people’s lives every day



Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association