The role is primarily responsible for designing and delivering Blue Cross Blue Shield of Minnesota classes to produce fully equipped, non-clinical and clinical resources to allow-them to successfully fulfill their role. The job focuses in providing training session on Utilization Management platform processes and procedures.
- Conducts comprehensive Intake training on receiving, researching, prioritizing and responding to Utilization Management, (UM) requests Case Management, Disease Management through mailbox management, system work queue management, incoming telephonic and written pre-service, post-service (pended claim), and concurrent care requests.
- Supervises outbound calls to providers and facilities as warranted, and to receive and route inbound calls from members, providers, customer service, or other internal stakeholders per Intake process.
- Monitors and evaluates an outstanding level of customer service throughout all points of customer contact.
- Ensure that the appropriate clinical staff receives the call, or written request in a timely manner and according to established practices, workflow processes, and departmental needs.
- Accurately apply specific guidelines, policies, and procedures as authorized by the clinical review areas.
- Ensures application of clinical experience, health plan benefit structure and claims payment knowledge to pre- service by facilitating gathering relevant and comprehensive clinical data through multiple sources.
- Monitors 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 resolution of quality issues and inappropriate claim submission.
- Provides guidance on reviewing and identifying issues related to professional and facility provider claims data including determining appropriateness of code submission, analysis of the claim rejection and the proper action to complete the retrospective review with the goal of proper and timely payment to provider and member satisfaction.
- Provides guidance in identifying potential discrepancies in provider billing practices and intervenes for resolution and education with Provider Relations, or if necessary, involving Special Investigation Unit.
- Quality and accuracy of deliverables
- Efficiency and effectiveness (result-orientation)
- Training delivery
- Adherence to internal standards
- Interaction with the clients/ customer at an appropriate level to ensure high levels of client satisfaction
- Employee satisfaction, people development and morale
- Good performance on any other function that may occur from time to time or as directed by the Supervisor
- Builds and maintains atmosphere where coaching, counseling, and feedback are considered essential for better performance
- Risk recognition, assessment, analyses, management and mitigation
- Demonstration of in-depth knowledge and application of various methodologies in relevant situations or phases
- Above average knowledge of MS Office applications like – PowerPoint, MS Word and MS Excel
- Internet usage and email access
- Local RN Licensing
- Nursing education
- Project management
- Process Specific Skills
- Training module development
- Ability to present the information in simple and easy to understand manner
- Ability to understand and comprehend quickly about unfamiliar industry
- Prioritizing customer needs
- Strong customer service focus
Soft Skills (Minimum)
- Above average verbal and written communication skills
- Above average presentation skills
- Flexibility and urgency to handle pressure
- Team work/ Self-sufficiency / Adaptability
- Self-disciplined and results oriented
- Data gathering ability/ Keen eye for detail
- Analytical skills
- Operational planning and process management
- Ability to multi task
- Ability to approach problems logically
- Interpersonal Skills
- Customer Service Focus
- Coaching and mentoring skills
Soft skills (Desired)
- Project management
- Basic domain knowledge
- Non-Clinical: College graduate
- Clinical: Graduate with at least 14 years of education with degree in Nursing and with active USRN license
Work Experience Requirements
- USRN Trainer – At least 1 year clinical + 2 years of HC experience
- Non-Clinical Trainer – At least 2 year HC experience