Medicare Advantage Case Management Nurse

Blue Cross and Blue Shield of Kansas•Topeka, KS

2d•$75,440 - $103,600•Hybrid

About The Position

The Medicare Advantage Case Management Nurse Non-Certified/Certified is primarily and independently responsible for the day-to-day operations of reviewing, processing, and communicating with members and providers involved in case management activities which may include determining appropriateness and cost effectiveness of care in light of quality-of-care objectives. This position serves as primary negotiator with medical providers/vendors regarding reimbursement and provider write off of services involved in specific managed care cases. Also carries primary responsibility for pre and post-case management claim payment. Provide backup support for precert activities. Responsible for performing all activities within State, URAC, HIPAA, DOL, CMS, and MTM goals or guidelines.

Requirements

Ability to communicate effectively, verbally, in writing and via telephone regarding sensitive and confidential issues and maintain a positive professional image.
Ability to assess, analyze, plan, and evaluate situations.
Ability to self-direct, make independent decisions, and prioritize daily activities.
Ability to handle sensitive situations in a positive, professional manner.
Must be comfortable discussing reimbursement/financial arrangements.
Schedule could require alternative work hours, which may include evenings, weekends, availability 365 days per year.
Registered nurse with minimum three years clinical nursing experience, acute medical/surgical preferred, Bachelor of Science in Nursing (BSN) preferred.
Current unrestricted Kansas RN license required.
Experience with government programs is helpful.
Current unrestricted Certification as a case manager (CCM) required.

Nice To Haves

Must become CCM certified within two years of assuming the position.

Responsibilities

Perform case management in compliance with URAC standards, CMS regulations, Kansas Nurse Practice Act, CMSA Standards of Practice, and CCMC guidelines, ensuring accurate documentation, activity monitoring, and audit reporting.
Coordinate and communicate case management inquiries across departments, including medical directors, customer service, claims, sales, provider relations, behavioral health vendors, and legal counsel.
Develop, implement, and monitor cost-effective treatment plans that meet patient needs and quality standards, coordinating care across multiple providers and care settings, and negotiating reimbursement when appropriate.
Provide clinical support for precertification, case management, and alternative care activities for commercial business lines.
Deliver onboarding, training, and guidance to new team members, and participate in multidisciplinary case management decision meetings involving patients, providers, caregivers, and facility representatives.
Maintain an appropriate caseload, ensuring timely documentation, follow-up, and continuous evaluation of care plans for effectiveness.