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Care Manager PreService & Retrospective Behavioral Health Utilization Management

Company: Blue Cross and Blue Sheild of Minnesota
Location: Saint Paul
Posted on: August 4, 2022

Job Description:

About Blue CrossBlue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.9 million members. We're committed to reinventing health care to improve health for our members and the community. We hope you'll join us. Please note that effective 11/23/2021, all associates must be fully vaccinated for COVID19 unless legally entitled to a reasonable accommodation related to religious or medical exemptions.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: Receives referral and/or reaches-out to member and uses clinical knowledge, motivational interviewing and behavioral modification techniques. Conducts comprehensive clinical assessments; gathers, analyzes, synthesizes and prioritizes member needs and opportunities. Collaborates and communicates with member, family, or designated representative on a plan of care that produces positive clinical results and promotes high-quality effective outcomes. Identifies relevant BCBSMN and community resources and facilitates warm program and network referrals. Monitors and evaluates plan of care over time. Ensures member data is documented according to BCBSMN application protocol and regulatory standards. Maintains outstanding level of service at all points of customer contact. Understands broad-based goals of assigned market segment(s) including clinical and service availability. Collaborates and coordinates with team members to facilitate day to day functions and enhance the overall operation of the department. Engage providers telephonically in reviewing and understanding treatment plans, including alignment with benefits and medical reimbursement policies to facilitate optimal treatment plans, care coordination, and transition of care between settings.Required Skills and ExperiencesClinician licensed for independent practice with one or more of the following licenses with no restrictions and 3 years relevant direct clinical care experience: Registered Nurse (RN) with Psychiatric experience Licensed Independent Clinical Social Worker (LICSW) Licensed Marriage and Family Practice (LMFT) Licensed Psychologist (LP) Licensed Professional Clinical Counselor (LPCC)Researching community resources and providing them to members pertaining to Social Determinants of Health (SDoH) needs Researching claims and cost drivers. Conducting outbound calls to members/families caregiver, providers and facilities calls to obtain discharge dates and discharge information.All relevant experience including work, education, transferable skills, and military experience will be considered. Excellent communication skills. Excellent conceptual thinking skills. Excellent relationship management skills. Excellent organizational skills. Computer application proficiency. Flexibility to work varied hours.Nice to Have: 1+ years of managed care experience; management/health coach, utilization management and/or auditing experience. Outstanding telephonic skills.Role Designation:TeleworkerRole designation definition: Teleworking is working full time remote. Hybrid is a combination of working onsite and remotely. Onsite is full-time onsite.Make a differenceBlue 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@.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.

Keywords: Blue Cross and Blue Sheild of Minnesota, St. Paul , Care Manager PreService & Retrospective Behavioral Health Utilization Management, Healthcare , Saint Paul, Minnesota

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