Case Management RN

Blue Cross and Blue Shield of Louisiana•Monroe, LA

3d•Onsite

About The Position

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us. Residency in or relocation to Louisiana is preferred for all positions. Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity. POSITION PURPOSE Utilize a collaborative process to assess, plan, implement, monitor, and evaluate options and services required to meet the member’s healthcare needs. Through communication, the case manager will identify available resources to promote quality, cost effective outcomes. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities. NATURE AND SCOPE This role does not manage people This role reports to this job: MANAGER, POPULATION HEALTH Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Benefits Administration, Medical Director, Underwriting, Group leaders, Delegated Vendors, Legal Department and other employees as needed, physicians/staff, hospital administrators/staff, providers, caregivers, subscribers, community resources

Requirements

Bachelor's in nursing, business administration, healthcare or a related field is required
RN license can be used in lieu of Bachelor's degree
Four years of related experience can be used in lieu of a Bachelor’s degree.
2 years of direct patient care/clinical experience required
Ability to research and analyze contracts/cases and make appropriate quality and cost effective decisions.
Strong communication skills, including the ability to effectively explain/present claims information and procedures to persons with varied levels of insurance/benefits understanding.
Excellent organizational and analytical skills.
Ability to make decisions, prioritize, find solutions, and work independently.
Working knowledge of related software and office equipment.
Active and unencumbered(current and unrestricted) RN license to practice in Louisiana is required.
Multi-state Compact RN license is required within 6 months from date of hire.
May be required to obtain additional RN licensure in noncompact state within 6 months from date of hire.
Certified Case Management Certification is required within 3 years from date of hire.

Nice To Haves

Residency in or relocation to Louisiana is preferred
Multi-state Compact RN license is preferred.
RN license in noncompact state is preferred.
Certified Case Management Certification is preferred.

Responsibilities

Assess member’s status by collecting in-depth information in culturally competent and confidential manner, about the member’s situation and functioning to identify individual needs in order to develop and implement a comprehensive case management plan that will address needs for moderated to high risk cases.
Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators. The case manager will act as an advocate for the member/family, maintaining privacy, confidentiality and safety, building relationships with all relevant parties, supporting informed decision making and facilitating access to necessary and appropriate healthcare services across the continuum of care.
Implement specific interventions and evaluate effectiveness that will lead to accomplishing the goals established in the plan. Experienced in behavioral interviewing techniques.
Coordinate by collaborating with the member/family, providers, third party payors, employers and community resources in order to organize, integrate, and modify the resources necessary to accomplish the goals. Assist with return to work, vocational development, and life care planning.
Responsible for meeting annual targets for program performance as mutually agreed to by management team to maximize program value. Participates in quality improvement projects and data collection to determine the effectiveness of the case management program.
Participates on project workgroups.
Familiar with guidelines and requirements for authorizations of services related to coordination of care for complex cases. Proficient in care management authorization processes, including usage of standard clinical guidelines such as milliman care guidelines, as part of management of complex case management cases.
Conduct case conferences with member, provider, and facilities as appropriate.
May provide guidance to less experienced nurses.
Perform other job-related duties as assigned, within your scope of responsibilities.