Care Manager - Appeals

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.

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 and resolution of quality issues for member and provider appeals. 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.

Applies clinical experience, health plan benefit structure and claims payment knowledge and gathers relevant and comprehensive clinical data through multiple sources for appeal reviews. 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.