Case Manager RN

Blue Cross Blue Shield of Michigan•Lansing, MI

7h•Remote

About The Position

The telephonic RN Case Manager position is responsible for utilizing the nursing process in the development of member treatment plans. The Case Manager will establish member goals and implement interventions to optimize member health care across an assigned patient caseload in order to promote high quality healthcare appropriate for the member’s clinical needs. Improve member health outcomes by successfully managing a member caseload from a variety of care management referral sources. Conduct telephonic member assessments to identify member care coordination needs; develop, with member and provider as appropriate, a specific care management plan to address member goals and interventions as identified during assessments. Manage members with chronic illness, co-morbidities, and/or complex health conditions to ensure the member receives quality health care in the most cost-effective and efficient delivery of healthcare benefits. Provide member and/or caregiver self-management strategies and ensure member receives appropriate level of post-care education to include education on condition(s), medication, benefits, and resources to optimize highest level of function. Identify potential gaps in member care through education, empowerment and/or motivational interviewing techniques. Coordinate internal and external resources to meet identified needs by assisting member with obtaining any DME supplies, pharmacy referrals, and/or community resources. Interfaces with Medical Directors and other interdisciplinary team members in the development of care management treatment plans. Familiarity with the quality management process and customer-focus care to improve STARS and HEDIS outcomes. Continues professional development by attending relevant educational programs at least annually. Ability to meet and/or exceed established productivity metrics and standards. Conduct comprehensive assessments of health, psychosocial needs, cultural preferences and support systems. Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care, and promotes improved overall health outcomes. Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services). Coordinate care delivery and support among member support systems, including providers, community-based agencies, family and other care management programs. Deliver education to include condition management including self-management, glucose monitoring, medication use, nutrition, physical activity, stress reduction, reducing complications, etc. Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate, as necessary. Accurately document interactions that support management of the member. Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals. Comply with applicable regulatory and licensing requirements such as NCQA and CMS. Monitor, evaluate and report programs' effectiveness (e.g., outcomes) and participate in continuous improvement activities. Advocate for members and promote self-advocacy.

Requirements

Nursing diploma or associate’s degree in nursing required.
Two (2) to four (4) years of related clinical experience required.
One (1) to three (3) years case management experience required.
Nursing experience in a clinical, acute/post-acute care, and community setting required.
Basic computer knowledge, typing ability, and proficiency in Microsoft Office products.
Effective written and verbal communication skills.
Ability to work independently yet remain engaged with team members as needed to meet performance metrics.
Effective organizational skills, ability to prioritize multiple tasks while maintaining flexibility.
Knowledge of Case Management and Disease Management principles.
Knowledge of medical surgical principals, discharge planning, chronic diseases and clinical programs.
Knowledge of HIPAA, American Disability Act, Clinical ethics, COB rules and Medical Policy.
Familiarity with InterQual criteria, crisis call interventions, evidence-based guidelines and alternate care.
Knowledge of educational assessments and learning strategies.

Nice To Haves

Bachelor’s degree in nursing or related field preferred.
Certification in Case Management (CCM) is preferred.
Certification in Chronic Care Professional (CCP) preferred.
Certified Diabetes Educator Specialist (CDE) or Certified Diabetes Care and Education Specialist (CDCES) preferred.
Managed care experience in Medicare case management preferred.
Experience in med surgical, preventive care, chronic condition education, homecare, critical care and public health preferred.

Responsibilities

Utilize the nursing process in the development of member treatment plans.
Establish member goals and implement interventions to optimize member health care.
Conduct telephonic member assessments to identify member care coordination needs.
Develop specific care management plans to address member goals and interventions.
Manage members with chronic illness, co-morbidities, and/or complex health conditions.
Provide member and/or caregiver self-management strategies.
Ensure member receives appropriate level of post-care education.
Identify potential gaps in member care through education, empowerment and/or motivational interviewing techniques.
Coordinate internal and external resources to meet identified needs.
Interface with Medical Directors and other interdisciplinary team members.
Conduct comprehensive assessments of health, psychosocial needs, cultural preferences and support systems.
Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care, and promote improved overall health outcomes.
Arrange resources necessary to meet identified needs.
Coordinate care delivery and support among member support systems.
Deliver education on condition management, self-management, glucose monitoring, medication use, nutrition, physical activity, stress reduction, and reducing complications.
Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan, and adjust as necessary.
Accurately document interactions that support management of the member.
Adhere to professional standards, protocols, rules, and guidelines.
Comply with applicable regulatory and licensing requirements such as NCQA and CMS.
Monitor, evaluate, and report programs' effectiveness and participate in continuous improvement activities.
Advocate for members and promote self-advocacy.