Case Management Nurse

Blue Cross and Blue Shield of Louisiana•Monroe, LA

About The Position

The Case Management Nurse focuses on members who have Medicare and are also entitled to Medicaid. The role conducts case management, care coordination, and quality activities in accordance with CMS standards and Blue Cross Blue Shield policies and procedures. Through telephonic assessments, the nurse evaluates member needs and requirements to help achieve or maintain optimal wellness. The nurse also identifies resource needs and guides members and their families toward appropriate resources, collaborating with members, care providers, and a multidisciplinary team to address physical, environmental, and psychosocial health issues. The position adheres to the Dual Plus Plan Model of Care and its program policies and objectives. It involves enrollment activities, individual assessments, care planning, coordination of community services, ongoing evaluation of member progress, and participation in interdisciplinary and quality improvement activities. The role does not manage people and reports to Departmental Leadership. Work is performed in a normal, clean office environment with normal noise levels, predominantly while standing or sitting. Residency in or relocation to Louisiana is preferred. Applicants must be authorized to work in the United States without employer-sponsored immigration support.

Requirements

High school diploma.
Four years of general clinic experience.
Currently licensed to practice in Louisiana as a Licensed Practical Nurse (LPN), with graduation from an accredited vocational or technical school for Practical Nursing; the posting states 180 days required.
Current Compact License or ability to obtain a Compact License within 90 days of hire.
Exceptional interpersonal, verbal, and written communication skills.
Ability to document clearly and concisely.
Strong problem-solving skills.
Ability to work with limited supervision and make decisions based on established policies and procedures.
Ability to meet expectations, take responsibility for results, maintain focus and attention to detail, and prioritize effectively.
Ability to model integrity, honor commitments, and take responsibility for the impact of one’s actions.
Ability to connect with customers and develop knowledge of their needs to provide valuable services and interactions.
Ability to leverage resources, make decisions amid ambiguity, resolve barriers, adapt to change, and apply new knowledge.
Understanding of, or ability to become knowledgeable about, quality monitoring and improvement activities.
Ability to comprehend, document, calculate, visualize, and analyze.
Authorization to work in the United States without employer-sponsored immigration support.

Nice To Haves

One year of clinical experience in case management, acute hospital discharge planning, or utilization review.
Previous direct clinical care to patients in a behavioral health setting.
Residency in or relocation to Louisiana.

Responsibilities

Adhere to Dual Plus Plan Model of Care program goals, objectives, policies, and procedures to meet members’ individualized health care needs.
Participate in enrollment activities.
Conduct telephonic case management and care coordination in communication with the multidisciplinary team.
Review cases individually and evaluate referrals to Social Services, Behavioral Health, Disease Management, community resources, and other resources.
Collect pertinent clinical information, including claims data when available, and document findings in the Acuity case management system.
Complete Health Risk Assessments covering physical, psychological, emotional, and environmental needs to guide appropriate and timely interventions.
Coordinate community care and services as appropriate.
Develop individualized care plans with members and/or families in collaboration with the Interdisciplinary Care Team (ICT).
Evaluate member progress, care-plan effectiveness, and the efficacy and appropriateness of services on an ongoing basis.
Consult and collaborate with relevant departments regarding care appropriateness, evidence-based clinical guidelines, medications, treatment plans, individualized care plans, and resource needs.
Serve as an active member of the ICT and participate in ICT meetings.
Participate in quality improvement processes.
Serve as a liaison and patient advocate when applicable or requested by the patient or the patient’s legally appointed representative.
Perform other job-related duties within the scope of responsibilities as assigned.