Population Health RN

Blue Cross and Blue Shield of Louisiana

About The Position

Responsible for organizing, coordinating, and providing care coordination and case management services to members who are most at risk for health deterioration, sentinel events, and/or poor outcomes. Manage acute and chronically ill members to improve health and financial outcomes through analysis of needs, design, and delivery of interventions. Utilize a collaborative process to assess, plan, implement, monitor, and evaluate options and services required to meet the member’s healthcare needs. Through communication, the nurse will identify available resources to promote quality, cost effective outcomes. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.

Requirements

Diploma in nursing or Associate’s in nursing or Bachelor's in nursing required.
3 years of recent direct patient care/clinical experience is required.
Requires the ability to prioritize, work independently and anticipate needs to make decisions.
Ability to plan, implement and evaluate appropriate healthcare services in conjunction with a physician treatment plan and evaluate the effectiveness of alternate care services are required.
Requires the ability to research and analyze contracts/cases and make appropriate quality and cost effective decisions.
Knowledge of standardized code sets and medical terminology is required.
Must demonstrate excellent interpersonal, organizational, analytical, and telephonic skills.
Must demonstrate strong communication skills, including the ability to effectively explain/present claims information and procedures to persons with varied levels of insurance/benefits understanding.
Requires working knowledge of related software and office equipment.
Active and unencumbered(current and unrestricted) RN license to practice in Louisiana is required.
Multi-state Compact RN license is required within 6 months from date of hire.
May be required to obtain additional RN licensure in noncompact state within 6 months from date of hire.
Certified Case Management Certification is required within 3 years from date of hire.

Nice To Haves

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

Responsibilities

In a culturally competent and confidential manner, assess member’s status by collecting in-depth information about the member’s situation and functioning to identify individual needs in order to develop and implement a comprehensive case management plan.
Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators.
The case manager will act as an advocate for the member/family, maintaining privacy, confidentiality and safety, building relationships with all relevant parties, supporting informed decision making and facilitating access to necessary and appropriate healthcare services across the continuum of care.
Implement a comprehensive case management plan.
Implement specific case management activities and/or interventions and evaluate effectiveness that will lead to accomplishing the goals established in the case management plan.
Coordinate by collaborating with the member/family, providers, third party payors, employers and community resources in order to organize, integrate, and modify the resources necessary to accomplish the goals.
Interacts with patients and/or providers in order to determine patient care needs, compliance and effectiveness with planned interventions and conduct case conferences as appropriate.
Evaluates the case management plan’s effectiveness in reaching desired outcomes and goals.
Modifies any or all of the case management plan’s components if necessary.
Utilizes behavioral interviewing techniques.
Familiar with guidelines and requirements for authorizations of services related to coordination of care for complex cases.
Proficient in care management authorization processes, including usage of evidence-based guidelines, as part of management of complex case management cases.
Responsible for meeting individual quality performance standards and annual targets for program performance, such as monthly productivity and annual caseload requirements, as mutually agreed to by management team to maximize program value.
Participates in Quality Improvement projects and data collection to determine effectiveness of Population Health Program.
May direct other staff in coordinating care.
Perform other job-related duties as assigned, within your scope of responsibilities.