About Blue Cross and Blue Shield of Minnesota

At Blue Cross and Blue Shield of Minnesota we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate you are joining a culture that is built on values of succeeding together finding a better way and doing the right thing. If you are ready to make a difference join us.

The Impact You Will Have

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 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.

Your 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 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.

Required Skills and Experience:

• Registered nurse or licensed behavioral health clinician (i.e. LICSW LPCC LMFT LP LADC) 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 inorder to ensure compliance.

Perferred Skills and Experience:

• 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.
• 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. ICD10 HCPCS and CPT).

Role Designation

Role designation definition: Teleworking is working full time remote. Hybrid is a combination of working onsite and remotely. Onsite is fulltime onsite.

Compensation and Benefits

Pay is based on several factors which vary based on position including skills ability and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical dental and vision insurance

• Life insurance

• 401k

• Paid Time Off (PTO)

• Volunteer Paid Time Off (VPTO)

• And more

To discover more about what we have to offer please review our benefits page.

Equal Employment Opportunity Statement

At Blue Cross and Blue Shield of Minnesota we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to and will not be discriminated against based on any legally protected characteristic.

Individuals with a disability who need a reasonable accommodation in order to apply please contact us at:

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