Case Manager, RN (Multiple Openings!)

Excellus BCBS•Rochester, NY

About The Position

Conducts case management program activities in accordance with departmental and corporate policies and applicable NYS Department of Health, CMS, Federal Employee Program, and NCQA requirements. Uses a systematic approach to identify eligible members and assess opportunities to educate, support, coach, coordinate care, and review treatment options in collaboration with providers and community resources. Works with cross-functional, multidisciplinary teams to implement member-centered interventions and develop comprehensive care plans addressing members’ needs and health goals while mitigating healthcare cost drivers. The position has three classification levels with increasing scope, independence, complexity, leadership, and subject-matter expertise. Level I handles physical health member clinical management programs and carries out the case management process, including identification, opening, assessment, education and support, care planning, interventions, reassessment, case closure, and case reviews. Level II handles all member clinical condition management programs, manages more complex assignments or larger caseloads, and mentors junior staff. Level III provides process and documentation expertise, supports escalations and staff development, and may back up the Supervisor/Manager in departmental operations. The role requires an active New York State license as an RN, Registered Dietitian, or Physical Therapist, depending on the applicable role requirements. Hospital to Home program incumbents have additional specified qualifications. Physical requirements include the ability to travel and work long hours on a computer; flexible hours may be required to accommodate member discussions.

Requirements

Associate degree required; bachelor’s degree preferred.
Active New York State licensure as an RN, Registered Dietitian, or Physical Therapist required, subject to the specified program requirements.
At least three years of clinical experience required.
Proficiency with Microsoft Office Suite.
Strong written and verbal communication skills.
Ability to multitask, balance priorities, and work independently on a daily basis.
For Federal Employee Program incumbents, Case Management Certification is required within two years of hire or moving into the role supporting the FEP line of business.
For Hospital to Home program incumbents only: active NYS RN license with three years of behavioral health experience, or LMSW, LCSW, or LMHC qualification.
Level II: at least two years in a case management position; ability to escalate matters to management as necessary; proficiency in related technology and documentation requirements; and consistent achievement of performance metrics.
Level III: at least five years in a current case management position or similar subject-matter-expert role; Case Management Certification; broad understanding of multiple areas such as UM and CM and their supporting systems; expertise handling complex assignments, challenging situations, and highly visible issues; ability to lead new-staff training; and demonstrated presentation skills.

Nice To Haves

Bachelor’s degree.
Case Management experience.
Experience interpreting managed care benefit plans and strong knowledge of Medicare and Medicaid government program contracts and benefits.
Level II: Case Management Certification.

Responsibilities

Screen members referred to the department or identified through data analysis and determine their appropriateness for case management services using established criteria and professional clinical judgment.
Initiate and open appropriate cases in a timely and effective manner.
Conduct the case management process, including member assessment, education and support, care planning, member-centered interventions, reassessment, outcome measurement, case closure, and case reviews.
Use motivational interviewing to disclose essential case management information and support members in meeting health goals.
Collaborate with members, caregivers, physicians, and other healthcare providers to assess needs, develop interdisciplinary care plans, coordinate services, evaluate effectiveness, and modify plans as needed.
Assess member and caregiver knowledge of illnesses and provide education to address knowledge deficits.
Work with members and caregivers to identify objectives, goals, actions, and barriers to achieving health goals.
Provide members with resources and assistance for managing health across the continuum of care.
Maintain current information about community resources and act as a liaison between providers and community resources.
Coordinate and collaborate with interdisciplinary teams, including Utilization Management, Quality, Behavioral Health, Pharmacy, Registered Dietitians, Respiratory Therapists, and other relevant professionals.
Participate in and promote health plan programs, including preventive health, web-based self-management tools, and digital health programs and applications.
Maintain knowledge of applicable case management standards, program activities, regulatory requirements, accreditation standards, licensure requirements, and scope-of-practice requirements.
Maintain confidentiality and follow corporate and departmental information-management and privacy policies.
Meet continuing education requirements and pursue professional growth.
Work with internal and external stakeholders on value-based payment programs when applicable.
Support the organization’s mission, values, and Code of Conduct; maintain reliable attendance and perform other duties as assigned.
At Level II, suggest and participate in process improvements, address complex issues, mentor junior staff, meet performance and productivity metrics, manage complex assignments or larger caseloads, and serve as a positive role model.
At Level III, identify and evaluate process improvements; assist with policies, procedures, desk manuals, and performance-improvement guidelines; serve as an expert for escalations; mentor and guide clinical staff; assist with staff orientation and training; help staff engage members in care; liaise with internal departments; and help ensure regulatory requirements are met.
At Level III, support departmental quality, productivity, utilization performance, and educational needs, and provide backup for the Supervisor/Manager when necessary.