About Blue Cross Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We're committed to reinventing health care to improve health for our members and the community. We hope you'll join us. How Is This Role Important to Our Work? 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. A Day in the Life: 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. Nice to Have: 5 years of R 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). Required Skills and Experiences: 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 inorder to ensure compliance. Make A Difference 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, gender expression, or any other legally protected characteristic. Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com. All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. Blue Cross and 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.