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Eagan MN Full Time Posted: Friday, 12 January 2018
 
 
Applicants must be eligible to work in the specified location

About Blue Cross

For more than 80 years, Blue Cross and Blue Shield of Minnesota has worked to improve the health of all Minnesotans. As a nonprofit organization, we have a long history of making a healthy difference in people's lives and of giving back to the communities we serve. In particular, our industry-leading commitment to veterans, service members and their families helped us to be named the first and only Beyond the Yellow Ribbon health plan company in Minnesota.

We make it easy for you to support veterans groups and other community organizations by providing 20 hours of volunteer paid time off each year - in addition to regular paid time off. The dedication of Blue Cross volunteers has earned us recognition for running one of the most successful corporate food drives in the state; donating nearly 1,500 volunteer hours at Habitat for Humanity worksites; and growing more than 750 pounds of fresh produce at our onsite Community Giving Gardens. Find your place at a company that cares about veterans, our employees, our members and our communities.

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 (eg 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. Retrospective - 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 without restrictions or pending restrictions.
  • 3 years of related, progressive clinical experience ( ie RN orLPN 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 (eg 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 (eg 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


Eagan MN, United States of America
Healthcare
Blue Cross Blue Shield of Minnesota
Blue Cross Blue Shield of Minnesota
JS19065-EN_US
1/12/2018 10:42:55 PM


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