Care Manager PreService & Retrospective

Blue Cross Blue Shield of Minnesota•Eagan, MN

11d•Remote

About The Position

Blue Cross and Blue Shield of Minnesota is hiring a Care Manager PreService & Retrospective. In this role, you will review and evaluate 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

3+ years of related case management (clinical) professional experience.
Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted.
Registered nurse or licensed behavioral health clinician (i.e. LICSW, LPCC, LMFT, LP, LADC, LBA) with current MN license and no restrictions or pending restrictions.
Registered Nurse Lic (RN) - State Nursing Licensing Board

Nice To Haves

Ability to tailor communication to varied audiences, actively listen to uncover requirements, and ensure accurate and timely information exchange.
Ability to analyze information, identify patterns and root causes, and collaborate with partners to implement practical solutions.
Ability to effectively organize work, balance competing priorities, and manage time across multiple responsibilities and deadlines.

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.
Performs additional responsibilities consistent with the scope and level of the role, as assigned.