Care Manager PreService & Retrospective - Behavioral Health

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.

Reviews and evaluates 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.

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. 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.