Medicare Advantage Case Management Triage Nurse

Blue Cross and Blue Shield of Kansas•Topeka, KS

2d•Hybrid

About The Position

The Medicare Advantage Case Management Triage Nurse is primarily and independently responsible for the day-to-day activities of researching, reviewing, processing, initial screening and triage of members identified in the resource utilization programs as well as those identified from any other source. Responsible for appropriate identification and referral of members for potential case management (CM) intervention. Responsible for testing discharge call outreach (DCO) system development as needed. Responsible for conducting all activities in compliance with State, URAC, HIPAA, DOL, CMS, and MTM goals and/or guidelines. This position is eligible to work hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

Requirements

Ability to communicate effectively, verbally, in writing, and via telephone regarding confidential and sensitive issues while maintaining a positive professional image.
Ability to problem solve using analytical reasoning and research.
Ability to self-direct, self-motivate, make independent decisions, and prioritize/organize daily activities.
Awareness and understanding of current medical care practices.
Associate Degree in Nursing (ADN) required.
Registered nurse with minimum three years RN clinical nursing experience required, acute medical/surgical preferred.
Must have a current, active, and unrestricted Kansas RN License.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Experience with government programs preferred.

Responsibilities

Responsible for collaborating/coordinating with the case managers and management to identify, clinically research and triage potential members for CM.
Responsible for coordinating CM identification activities with case managers and other area staff for optimal efficiency of processes.
Responsible for activities and collaboration with other areas of the company (e.g. health analytics, disease management) to identify and promote management of appropriate Blue Cross and Blue Shield of Kansas (BCBSKS) members and achievement of other corporate goals (e.g. HEDIS/Stars) which may involve participation of the CM area.
Perform initial clinical review on referred cases.
Responsible for triage of referred cases to other programs or resources as needed (e.g. pharmacy, disease management, rare disease management, other wellness programs, etc.)
Conducts review of medical information without direct supervision.
Must determine through independent medical knowledge which cases require CM input or medical consultant expertise. All such determinations must be made under limited time constraints.
Assist in answering the general CM telephone lines for all lines of business and triaging the calls to the appropriate case manager, other area of the company, or handle as appropriate.
Maintain appropriate activity level and case documentation to meet URAC, CMS, group and/or corporate requirements.
Responsible for performing all job functions within the scope of the Kansas Nurse Practice Act.
Responsible for delivering onsite training and orientation for new department employees.
Responsible for conducting resource utilization program activities (e.g. post discharge member contact, avoidable emergency department use, etc.).