Population Health RN

Blue Cross and Blue Shield of Louisiana•Remote-LA, LA

About The Position

The Population Health RN organizes, coordinates, and provides care coordination and case management services for members at greatest risk of health deterioration, sentinel events, or poor outcomes. The role manages acute and chronically ill members to improve health and financial outcomes by analyzing needs and designing and delivering interventions. Using a collaborative process, the nurse assesses, plans, implements, monitors, and evaluates options and services needed to meet members’ healthcare needs, identifying available resources to promote quality and cost-effective outcomes. The role complies with applicable laws, regulations, and accreditation standards and does not manage people. It reports to the Manager, Population Health. The position works with internal departments and colleagues, physicians and other providers, hospitals, caregivers, subscribers, and community resources. Duties are performed in a normal, clean office environment with normal noise levels, and work is predominantly done while standing or sitting. The role may direct other staff in coordinating care. Louisiana residency or relocation is preferred. Applicants must be authorized to work in the United States without employer-sponsored immigration support.

Requirements

Diploma in nursing, Associate’s degree in nursing, or Bachelor’s degree in nursing.
At least 3 years of recent direct patient care or clinical experience.
Active, unencumbered, current and unrestricted RN license to practice in Louisiana.
Obtain a multi-state Compact RN license within 6 months of hire.
Obtain Certified Case Management Certification within 3 years of hire.
Ability to prioritize, work independently, anticipate needs, and make decisions.
Ability to plan, implement, and evaluate healthcare services in conjunction with a physician treatment plan, and evaluate the effectiveness of alternate care services.
Ability to research and analyze contracts and cases and make appropriate quality and cost-effective decisions.
Knowledge of standardized code sets and medical terminology.
Excellent interpersonal, organizational, analytical, and telephonic skills.
Strong communication skills, including the ability to explain and present claims information and procedures to people with varied levels of insurance and benefits understanding.
Working knowledge of related software and office equipment.

Nice To Haves

2 years of managed care experience.
Experience using behavioral interviewing techniques and theory.
Multi-state Compact RN license.
RN license in a noncompact state.
Certified Case Management Certification.

Responsibilities

Assess members’ status by gathering in-depth information about their situations and functioning, identifying needs, and developing a comprehensive case management plan in a culturally competent and confidential manner.
Develop case management objectives, goals, and actions using specific, time-oriented indicators; advocate for members and families, protect privacy and safety, support informed decision-making, and facilitate access to appropriate healthcare services.
Implement comprehensive case management plans and interventions, and evaluate their effectiveness in meeting established goals.
Coordinate and integrate resources with members and families, providers, third-party payors, employers, and community resources; modify resources as needed to achieve goals.
Interact with patients and/or providers to determine care needs, compliance, and the effectiveness of planned interventions; conduct case conferences as appropriate.
Evaluate case management plans against desired outcomes and goals and modify plan components when necessary.
Use behavioral interviewing techniques.
Apply authorization guidelines and requirements for services related to complex care coordination, including evidence-based guidelines and care management authorization processes.
Meet individual quality performance standards and annual program targets, including agreed-upon monthly productivity and annual caseload requirements.
Participate in Quality Improvement projects and data collection to assess Population Health Program effectiveness.
Direct other staff in coordinating care when needed.
Perform other job-related duties within the scope of responsibilities.