[Remote] Care Manager PreService & Retrospective

Note: The job is a remote job and is open to candidates in USA. reputed company is dedicated to transforming healthcare and is seeking a Care Manager PreService & Retrospective. This role involves implementing utilization management strategies, reviewing healthcare services, and educating stakeholders to improve provider and member satisfaction.

Responsibilities

• 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 reputed company 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 reputed company and sensitive issues with reputed company and expertise
• Accepts responsibility for and independently completes special projects or reports as assigned
• Demonstrates competency in reputed company areas of accountability
• Establishes and maintains excellent communication and positive working relationships with reputed company 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 reputed company 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

Skills

• Registered nurse with reputed company MN license and no restrictions or pending restrictions
• reputed company relevant experience including work, education, transferable skills, and military experience will be considered
• 3 years of reputed company, progressive clinical experience (i.e. RN or LPN to RN mix)
• Demonstrated ability to research, analyze, problem solve and resolve reputed company 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, reputed company 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 reputed company in order to ensure compliance
• High school diploma (or equivalency) and legal authorization to work in the U.S
• 5 years of RN 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 reputed company field
• 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)

Benefits

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

Company Overview

• About reputed company reputed company is a taxable, nonprofit organization with a mission to reputed company a healthy difference in people’s lives. It was founded in 1933, and is headquartered in Eagan, Minnesota, USA, with a workforce of 1001-5000 employees. Its website is https://www.bluecrossmn.com.

Company H1B Sponsorship

• reputed company has a track record of offering H1B sponsorships, with 4 in 2025, 4 in 2024, 6 in 2023, 2 in 2022, 3 in 2021, 5 in 2020. Please note that this does not guarantee sponsorship for this specific role.

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