Job Description

About Blue Cross and Blue Shield of Minnesota

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

The Impact You'll Have

Blue Cross and Blue Shield of Minnesota is hiring a Care Manager PreService & Retrospective. In this role, you will review and evaluate requested medical or behavioral health service claims by reviewing clinical documentation, applicable policies, and line-of-business guidelines to determine appropriateness. This role involves comparing service requests to records and established criteria to make informed determinations on each case.

What You'll Do

• Review service requests and associated documentation to determine appropriateness based on policy, clinical guidelines, and line-of-business requirements.
• Conduct thorough chart reviews, render decisions, and document outcomes promptly to maintain workflow efficiency.
• Manage assigned case volume and achieve daily productivity goals, typically completing an target number of cases per day, with targets varying by team.
• Collaborate with physicians and other clinical professionals as needed to ensure accurate determinations and adherence to regulatory standards.
• Ensure decisions comply with state and federal regulations, benefit plans, and organizational policies, maintaining accuracy and consistency.
• Work within strict timelines and adapt to shifting priorities, managing multiple cases and urgent requests under tight turnaround requirements.

How You'll Do It

• Support team expansion efforts by mentoring new associates and sharing best practices to improve overall performance and case throughput.
• Participate in side projects and process improvement initiatives, collaborating with peers and leadership to enhance operational efficiency.
• Performs additional responsibilities consistent with the scope and level of the role, as assigned.

Required Skills & Experience

• 3+ years of related case management (clinical) professional experience.
• Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted.
• Registered nurse or licensed behavioral health clinician (i.e. LICSW, LPCC, LMFT, LP, LADC, LBA) with current MN license and no restrictions or pending restrictions.

Preferred Skills & Experience

• Ability to tailor communication to varied audiences, actively listen to uncover requirements, and ensure accurate and timely information exchange.
• Ability to analyze information, identify patterns and root causes, and collaborate with partners to implement practical solutions.
• Ability to effectively organize work, balance competing priorities, and manage time across multiple responsibilities and deadlines.

Licensure/Certifications

Required certification for this role: Registered Nurse Lic (RN) - State Nursing Licensing Board

Role Designation

Teleworker

Role designation definition:

• Teleworking is working full time remote.
• Hybrid is a minimum of 2 days onsite.
• Onsite is full-time onsite.

Compensation and Benefits

$33.13 - $43.89 - $54.66 Hourly

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

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

To discover more about what we have to offer, please review our benefits page.

Equal Employment Opportunity Statement

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan, as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to, and will not be discriminated against based on any legally protected characteristic.

Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talent.acquisition@bluecrossmn.com.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

Physical requirements.