RN Case Manager l Registered Nurse l Federal Employee Program

Company: BlueCross and BlueShield of Massachusetts
Location: Quincy
Posted on: November 22, 2021

Job Description:

Ready to help us transform healthcare? Bring your true colors to blue. The Telephonic RN Case Manager focuses on arranging and coordinating services that a member needs to get well or stay well. The Telephonic Case Manager also works to remove barriers that prevent the member from engaging in an appropriate plan of care. The Telephonic RN Case Manager demonstrates strengths working independently as well as collaboratively within a highly matrixed environment. The Telephonic RN Case Manager will be working with a team of other dedicated and compassionate nurses and providers to help meet department business objectives and measures. The Telephonic RN Case Manager will be using a member-centric, collaborative process involving assessment, planning, targeted intervention and advocacy, for our members. The Telephonic RN Case Manager will work with the member to identify options and services that meet their specific health needs through the health care continuum to promote optimal, cost-effective outcomes. RESPONSIBILITIES: * Uses clinical tools and information / data review to conduct comprehensive assessments of referred member's needs / eligibility * Determines approach to case resolution and creates comprehensive case management plans * Evaluates member's benefit plan and available internal and external programs / services * Interpretation and application of relevant criteria and guidelines, standardized case management processes, policies, and regulatory standards * Educates members on benefits, services, resources, alternative funding, and health care alternatives * Utilizes negotiation skills to secure appropriate services to meet the member's healthcare needs * Interacts with treatment providers, PCPs, and physicians as needed to support the plan of care * Regularly interacts with supervisors, managers, and physicians to discuss questions and concerns regarding specific cases * Presents cases at rounds and follows up with physicians as necessary to obtain physician input and achieve optimal outcomes for our members * Monitors for clinical quality concerns and refers appropriately * Identifies and escalates quality of care issues through established channels * Monitor clinical care services provided to members to optimize clinical outcomes * Provides telephone triage, crisis intervention and emergency response as situations arise * Utilizes case management and quality management processes in compliance with regulatory guidelines and company policies and procedures * Performs regular interventions and interactions with members to maintain the appropriate engagement level based on the course of situation / disease * Closes cases in a timely manner while maintaining member satisfaction QUALIFICATIONS & TRAINING: * Ability to adapt and be flexible to change * Strong team-work and communication skills as well as ability to be self-directive * Ability to analyze information to construct effective solutions * Execution and results (ability to set goals, follow processes, meet deadlines, and deliver expected outcomes with appropriate sense of urgency) * Cultural competence (demonstration of awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population) * Clinical assessment (ability to interpret, evaluate, and clearly document complex medical information using a directive and focused approach in order to identify relevant and actionable conditions, circumstances, and behaviors) * Care planning (ability to identify and clearly document member-driven, specific, measurable activities that address actionable conditions, circumstances, and behaviors in order to improve health outcomes and cost-effectiveness of services) * Member collaboration and engagement (ability to secure and maintain the motivation, participation, and collaboration of all relevant parties in a purposeful plan to improve health outcomes and cost-effectiveness of service delivery EDUCATION/TRAINING: * Minimum 3-5 years working as a Registered Nurse AND have worked in one or more in the following clinical settings within the last 12 months: inpatient, medical-surgical unit, critical care unit, telemetry unit, sub-acute unit, skilled nursing facility, VNA, home care, LTAC, and/or extended care facilities * Active Massachusetts RN License is required. Licensure in additional states, a plus. Please Note: Any restrictions against a license must be disclosed and reviewed * Demonstrated knowledge working with Microsoft Word, Outlook, PowerPoint, and Excel * Managed care plans and health insurance experience is a plus * Bachelor's degree in nursing, is preferred * Certified Case Manager (CCM), is preferred SCHEDULE OF HOURS: * Flexibility is required * Standard working hours are Monday through Friday 8:30 - 4:30pm Minimum Education Requirements: High school degree or equivalent required Location Quincy Time Type Full time

Keywords: BlueCross and BlueShield of Massachusetts, Quincy , RN Case Manager l Registered Nurse l Federal Employee Program, Executive , Quincy, Massachusetts