Clinical Nurse, Case and Disease Management - High Cost Claims

Blue Cross and Blue Shield of Kansas City

115d

About The Position

Utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote optimal, cost-effective outcomes. Transplant only: Provides prior authorization for, coordinates, and individually manages all member transplants. Acts as an internal and external customer resource for interpretation of transplant benefits and transplant-related claim adjudication. Serves as a company expert on current and future transplant types. The candidate for this position must reside in the Kansas City metropolitan area.

Requirements

• Associate degree in nursing
• 3 years full-time direct patient care clinical experience in either of the following: transplant, oncology or medical/surgical
• Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Thorough knowledge of URAC and NCQA® guidelines and state and federal regulations.
• Valid and active Registered nurse (RN) in Missouri and Kansas.
• Case Management Certification within 3 years of hire date or within 3 years of transfer to Case Management role/department.

Nice To Haves

• Bachelor’s degree in nursing with minimum of 5 years' experience, including at least three years' of case management and clinical transplant experience
• Valid and active Registered nurse (RN) licensure in all 50 states and the District of Columbia initiated within 6 months and completed within 15 months of hire date.
• Intermediate level keyboarding skills
• Intermediate level knowledge of FACETS UM, CM and claims applications.
• Experience in working with Health and Wellness and programs or an understanding of wellness principles
• Thorough knowledge of NCQA® guidelines and state and federal regulations
• Intermediate level knowledge of Milliman guidelines.

Responsibilities

• Completes member assessments by collecting and analyzing information across the seven domains of health and develops and implements individualized care plans with appropriate interventions in a culturally sensitive way.
• Uses standardized tools to complete assessments in the areas of clinical, functional, financial, support system, psychosocial and cognitive and environmental realms.
• Monitors effectiveness of plan of care by gathering sufficient information from relevant sources in order to intervene, as appropriate, to improve health outcomes.
• Determines appropriate intervals for monitoring plan of care.
• Utilizes internal, community and other healthcare resources to maximize outcomes.
• Acts as liaison between member, employer, providers, support system and BlueCross BlueShield of Kansas City.
• Works with multiple members of the healthcare team to foster continuity and coordination of care.
• Prioritizes interventions based on clinical need and readiness to change.
• Educates and works with members at different educational and health literacy levels.
• Utilizes clinical knowledge and critical thinking skills to individualize evidence based interventions.
• Assesses the member’s need for education and tailors teaching to the member’s knowledge level and learning style.
• Meets individual quality performance standards and annual targets for program performance as mutually agreed to by management team to maximize program value.
• Ensures compliance with applicable URAC and NCQA guidelines and state and federal regulations.
• Meets targets for program performance, such as monthly productivity and annual caseload requirements as mutually agreed to by management team to maximize program value.
• Schedules time effectively.
• Works with minimal supervision.
• Handles multiple projects simultaneously.
• Prioritizes work appropriately.
• Provides prior authorization of the transplant and manages individual member cases.
• Reviews transplant evaluation and authorizes in accord with medical policy.
• Opens case and follows NCQA case management standards.
• Documents transplant authorization, issues authorization letters, and follows in FACETS UM system in accord with UM concurrent review guidelines.
• Consults with Medical Director on cases outside medical policy, notifies providers and members, if transplant benefits are denied, and explains appeal rights.
• Educates members, providers, and other customers regarding transplant benefits.
• Directly educates the transplant financial coordinator of the transplant center, member and/or family members, brokers, group and marketing reps, and other providers.
• Directly educates internal customer service reps regarding individual transplant benefits and the transplant network.
• Ensures proper payment of pre-transplant, transplant, and post-transplant claims.
• Sets up transplant pre-pay review for each individual claim.
• Reviews transplant billing packets and reconciles with transplant centers if necessary.
• Continuously reviews FACETS claim history to determine if claim has been paid or if adjudication problems are occurring.
• Follows up with member and transplant center during the global payment process to ensure accurate payment.
• Responds to claims inquiries.
• Accurately reports potential high cost members and tracks costs on members currently undergoing transplants.
• Serves as transplant information source for other departments of the company.

Benefits

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
• Annual incentive bonus plan based on company achievement of goals
• Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities, and tuition reimbursement program
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

What This Job Offers

• Education Level: Associate degree
• Number of Employees: 101-250 employees