Care Manager PreService & Retrospective - Behavioral Health

Blue Cross Blue Shield of Minnesota•Eagan, MN

18h•Remote

About The Position

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 Reviews and evaluates requested medical or behavioral health service claims by reviewing clinical documentation, applicable policies, and line-of-business guidelines to determine appropriateness. This role involves comparing service requests to records and established criteria to make informed determinations on each case.

Requirements

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.

Nice To Haves

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. ICD-10, HCPCS, and CPT).

Responsibilities

Review service requests and associated documentation to determine appropriateness based on policy, clinical guidelines, and line-of-business requirements.
Conduct thorough chart reviews, render decisions, and document outcomes promptly to maintain workflow efficiency.
Manage assigned case volume and achieve daily productivity goals, typically completing an target number of cases per day, with targets varying by team.
Collaborate with physicians and other clinical professionals as needed to ensure accurate determinations and adherence to regulatory standards.
Ensure decisions comply with state and federal regulations, benefit plans, and organizational policies, maintaining accuracy and consistency.
Work within strict timelines and adapt to shifting priorities, managing multiple cases and urgent requests under tight turnaround requirements.
Support team expansion efforts by mentoring new associates and sharing best practices to improve overall performance and case throughput.
Participate in side projects and process improvement initiatives, collaborating with peers and leadership to enhance operational efficiency.