Population Health RN

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

19h

About The Position

Responsible for organizing, coordinating, and providing care coordination and case management services to members at greatest risk of health deterioration, sentinel events, or poor outcomes. The nurse 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, identifies available resources, and promotes quality, cost-effective outcomes. The role must comply with applicable laws, regulations, and accreditation standards. This position does not manage people and reports to the Manager, Population Health. The role involves contact with internal departments and colleagues, physicians and their staff, hospital administrators and staff, providers, caregivers, subscribers, and community resources. The position’s duties are performed in a normal, clean office environment with normal noise levels. Work is predominately performed while standing or sitting. The employee must be able to comprehend, document, calculate, visualize, and analyze. Residency in or relocation to Louisiana is preferred. Applicants must be authorized to work in the United States without employer-sponsored immigration support. The employer conducts background checks and pre-employment drug screening after an offer and before hire; the position is in a drug-free workplace, and company properties are smoke- and tobacco-free.

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 appropriate healthcare services in conjunction with a physician’s treatment plan, and assess the effectiveness of alternate care services.
Ability to research and analyze contracts and cases and make quality, 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 varying 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 (preferred in addition to the requirement to obtain one within 6 months of hire).
RN license in a noncompact state; additional RN licensure in a noncompact state may be required within 6 months of hire.
Certified Case Management Certification (preferred in addition to the requirement to obtain it within 3 years of hire).
Residency in or relocation to Louisiana.

Responsibilities

Assess members’ status in a culturally competent and confidential manner by collecting in-depth information about their situations and functioning, identifying individual needs, and developing and implementing comprehensive case management plans.
Determine objectives, goals, and actions through assessment, using action-oriented and time-specific indicators.
Advocate for members and families, protect privacy, confidentiality, and safety, build relationships with relevant parties, support informed decision-making, and facilitate access to appropriate healthcare services across the continuum of care.
Implement comprehensive case management plans and specific case management activities or interventions, and evaluate their effectiveness in achieving established goals.
Collaborate with members and families, providers, third-party payors, employers, and community resources to organize, integrate, and modify resources needed to accomplish care 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 guidelines and requirements for service authorizations related to complex care coordination, including evidence-based guidelines and care management authorization processes.
Meet individual quality performance standards and annual program targets, including monthly productivity and annual caseload requirements agreed upon with management.
Participate in Quality Improvement projects and data collection to assess Population Health Program effectiveness.
May direct other staff in coordinating care.
Perform other job-related duties within the scope of responsibilities.