Posted: Wednesday, November 8, 2017 5:00 AM
About Blue Cross
Founded in 1933, Blue Cross and Blue Shield of Minnesota is the largest health plan in the state. We have more members, the largest network of providers and more products and services than any other plan in Minnesota. From the beginning, Blue Cross has been an innovator with a mission of making a healthy difference in people's lives.
We understand the importance of finding a job that you truly enjoy - at a company that shares your values. We've made it easy to feel good about working at Blue Cross by encouraging volunteerism, valuing diversity and offering the flexibility you need to live a balanced life. We offer a suite of comprehensive medical and dental benefits as well as competitive pay, flexible work schedules and generous personal paid time off in addition to 20 hours of volunteer paid time off each year. We look forward to serving Minnesotans over the next 80 years and beyond. Join us and make a healthy difference through the work you do every day.
Description Summary 13;
The position is responsible for promoting appropriate, effective and efficient use of health care resources via pre: and post:service review, appeals and program and network referrals. The scope of this position includes the review of clinical care and treatment plans by staff in IHM and CSC departments. Additionally, the Senior UM Specialist serves as a subject matter expert to team members and Blue Cross. 13;
:Applies clinical experience, health plan benefit structure and claims payment knowledge to pre: and post:service reviews.
:Gathers relevant and comprehensive clinical data through multiple sources.
:Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
:Maintains outstanding level of service at all points of contact (e.g. members, contract accounts).
:Collaborates and maintains positive, effective working relationships with all internal and external stakeholders
: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.
:Completes case documentation according to regulatory standards and clinical procedures.
:Accepts responsibility for and completes special projects or reports as assigned.
:Recognizes and raises any trends and emerging issues to management and recommends best practices for workflow improvement.
:May be required to assist other UM teams as needed.
: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 effective communications and positive working relationships within and outside of the organization.
:Registered nurse with current MN license without restrictions or pending restrictions.
:3 years relevant clinical experience
:1 years of managed care experience; e. g. case management, utilization management and/or auditing experience
:Demonstrated ability to research, analyze, problem solve and resolve complex 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, when appropriate, issues pertaining to differences in expectations of coverage, eligibility and appropriateness of treatment conditions.
:Maintains a thorough and comprehensive understanding of state
• Location: Minneapolis / St. paul
• Post ID: 26463287 minneapolis