RN Case Manager - Care Advocacy

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.

This position exists to support member needs across the continuum of care by leveraging member partnership, pre-service clinical utilization review, case and disease management processes, skill sets and tools. Care Advocacy Case Manager is responsible for answering customer questions pertaining to product information, benefits, claims resolution and eligibility in a call center environment. This position is a critical component of BCBSMN Medical Management team as the primary clinician providing condition and case management services to members.

Serves as a customer advocate by identifying underlying customer needs and guiding them to appropriate programs and resources. Utilizes BCBSMN customer service systems and tools to deliver Care Advocacy to designated accounts. Identifies opportunities for connecting members to group related benefits; e.g. Nurse Line, Employee Assistance Program, or other specialists with in BCBS Health Management Division. Educates members on the use of their health delivery system and tools. Participates as a resource to internal and external customers. Responsible for answering customer questions pertaining to product information, benefits, claims resolution and eligibility in a call center environment. Conducts comprehensive clinical assessments; gathers, analyzes, synthesizes and prioritizes member needs and opportunities. Develops a plan of care to address identified gaps in care and improve members health. Collaborates and communicates with member, family, or designated representative on a plan of care that produces positive clinical results and promotes high-quality effective outcomes. Identifies relevant BCBSMN and community resources and facilitates warm program and network referrals. Monitors and evaluates plan of care over time. Ensures member data is documented according to BCBSMN application protocol and regulatory standards. Collaborates and coordinates with team members to facilitate day to day functions and enhance the overall operation of the department. Guides member through the Prior Authorization and Appeals process. Engage providers telephonically in reviewing and understanding treatment plans, including alignment with benefits and medical reimbursement policies to facilitate optimal treatment plans, care coordination, and transition of care between settings.