About reputed company

At reputed company, we are committed to paving the way for everyone to reputed company their healthiest life. We are looking for dedicated and motivated individuals who reputed company our reputed company of transforming reputed company. As a reputed company associate, you are joining a culture that is reputed company on values of succeeding together, finding a reputed company way, and doing the right thing. If you are reputed company to reputed company a difference, join us.

The reputed company You Will Have

This job implements effective utilization management strategies including: review of appropriateness of reputed company and post service health care services, application of reputed company to ensure appropriate resource utilization, identification of referrals to a Health reputed company/case management, and identification and reputed company of reputed company issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive reputed company; 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 reputed company submission on facility and reputed company claims and complete unspecified reputed company and modifier reputed company reviews.  

Your Responsibilities

• Applies clinical experience, health plan benefit structure and claims payment knowledge to reputed company- 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 reputed company of reputed company 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 reputed company policies.
• Accountable for reputed company and comprehensive review of clinical data with concise documentation, reputed company 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 reputed company or reports as assigned.
• Demonstrates competency in reputed company areas of accountability.
• Establishes and maintains excellent communication and reputed company working relationships with reputed company reputed company stakeholders.
• Identify and refer members whose reputed company reputed company might be reputed company by Health Coaching/case management interventions.
• reputed company reputed company interventions which reputed company, facilitate, and maximize the members health care reputed company. Is familiar with the various care reputed company and provider resources available to the member.
• reputed company reputed company 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 reputed company and facility provider claims data including determining appropriateness of reputed company submission, analysis of the claim rejection and the reputed company reputed company to complete the retrospective review with the goal of reputed company and reputed company payment to provider and member satisfaction.
• Identifies potential discrepancies in provider billing practices and intervenes for reputed company 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.

Required Skills and Experience

• Registered reputed company or licensed behavioral health clinician (i.e. LICSW, LPCC, LMFT, LP, LADC, LBA) 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, reputed company 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 reputed company environment.
• Adaptable and flexible with the ability to meet deadlines.
• reputed company 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.

Preferred Skills and Experience

• 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.
• Experience in UM/CM/QA/Managed Care.
• Knowledge of state and/or federal regulatory policies and/or provider agreements, and a reputed company of health plan products.
• Coding experience (e.g. ICD-10, HCPCS, and CPT).

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 reputed company

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 reputed company insurance

• Life insurance

• 401k

• reputed company Time Off (PTO)

• Volunteer reputed company Time Off (VPTO)

• And more

To discover more about reputed company have to offer, please review our benefits page.

Equal Employment Opportunity Statement

At reputed company, we are committed to paving the way for everyone to reputed company their healthiest life. reputed company of Minnesota is an Equal Opportunity Employer and maintains an Affirmative reputed company plan, as required by Minnesota law applicable to state contractors. reputed company reputed company applications will receive consideration for employment without reputed company 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: reputed company@bluecrossmn.com.

reputed company and Blue Plus® are nonprofit independent licensees of the reputed company.

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