Blue Cross and Blue Shield of Minnesota · 6 hours ago
Care Manager PreService & Retrospective
United States
Full-time
Remote
Mid, Senior Level
$33.13/hr - $54.66/hr
3+ years expBlue Cross and Blue Shield of Minnesota is dedicated to transforming healthcare and is seeking a Care Manager PreService & Retrospective. This role involves implementing utilization management strategies, reviewing healthcare services, and educating stakeholders to improve provider and member satisfaction.
Insurance
Responsibilities
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
Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness
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
Maintains outstanding level of service at all points of contact (e.g. members, providers, contract accounts)
Maintains confidentiality of member and case information by following corporate and divisional privacy policies
Accountable for timely and comprehensive review of clinical data with concise documentation, decisions and rationale, according to regulatory standards and procedures
Recognizes and raises any trends and emerging issues to management and recommends best practices for workflow improvement
Mentors, coaches and fulfills the role of preceptor
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
Establishes and maintains excellent communication and positive working relationships with all internal and external stakeholders
Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions
Employ collaborative interventions which focus, facilitate, and maximize the members health care outcomes. Is familiar with the various care options and provider resources available to the member
Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships
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
Identifies potential discrepancies in provider billing practices and intervenes for resolution and education with Provider Relations, or if necessary involve Special Investigation Unit
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
Qualification
Required
Registered nurse with current MN license and no restrictions or pending restrictions
All relevant experience including work, education, transferable skills, and military experience will be considered
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 in order to ensure compliance
High school diploma (or equivalency) and legal authorization to work in the U.S
Preferred
5 years of RN or relevant clinical experience
1+ years of managed care experience (e.g. case management, utilization management and/or auditing experience)
Bachelors degree in nursing
Certification in utilization management or a related field
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)
Benefits
Medical, dental, and vision insurance
Life insurance
401k
Paid Time Off (PTO)
Volunteer Paid Time Off (VPTO)
And more
Company
Blue Cross and Blue Shield of Minnesota
About Blue Cross Blue Cross and Blue Shield of Minnesota is a taxable, nonprofit organization with a mission to make a healthy difference in people’s lives.
1001-5000 employees
H1B Sponsorship
Blue Cross and Blue Shield of Minnesota has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (4)
2024 (4)
2023 (6)
2022 (2)
2021 (3)
2020 (5)
Funding
Current Stage
Late StageLeadership Team
Carrie S. Lawrence
Executive Administrator to the President & CEO and Chief of Staff
Patsy Riley
Chief Goverment Officer and Senior Vice President and CEO, ClearStone Solutions
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