RN Case Manager

Blue Cross Blue Shield of Massachusetts•Hingham, MA

5d•$44 - $54•Onsite

About The Position

The Clinical Care Manager is responsible for facilitating care for members and families of members who may have rising health risks or complex healthcare needs, to promote optimal health. This position is self-directed and works independently and collaboratively to facilitate care based on the principles of care management. Facilitation is focused on assessing needs, identifying health care disparities, social determinants of health, and any barriers to care. The Clinical Care Manager will engage members in appropriate plans of care, coordinate care and services as appropriate, communicate effectively and provide members with education and resources as needed. The Clinical Care Manager is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care.

Requirements

Ability to identify and document member-driven, specific, measurable activities that address actionable behaviors and goals
Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
Ability to assess, analyze, draw conclusions, and construct effective solutions.
Excellent written and verbal communication skills.
Proficient with multiple IT systems.
Able to identify and set goals, follow processes, meet deadlines, and deliver expected outcomes with the appropriate sense of urgency.
Ability to interpret, evaluate, and document complex medical information to identify relevant and actionable conditions, circumstances, and behaviors.
Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
Willingness to learn new business and clinical skills
3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).
Active licensure in Massachusetts is required, appropriate to position (RN, LMHC, LICSW, LCSW)
For Registered Nurses Only: A Bachelor’s degree in nursing (BSN) is preferred
For Behavioral health position, a RN, LMHC, LICSW or LCSW is required
Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above

Nice To Haves

Case Management experience preferred
Certifications such as Case Management (CCM), certified diabetic educator, and Wellcoach certification a plus.
Licensure in additional states a plus.

Responsibilities

Continually assess and evaluate member and family needs utilizing strong communication skills, critical thinking, clinical knowledge, data, and tools.
Promote member compliance with treatment plan, encourage shared decision-making, and set appropriate goals to promote optimal member outcomes.
Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow and appropriately document comprehensive care management plans.
Review medication list and educate members with complex pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.
Successfully connect, engage, and maintain member engagement to support seamless care transitions and optimized health outcomes.
Collaborate within a team of professionals, including clinical utilization managers, account representatives, member service associates, dietitians, and physicians, to provide members with a high level of care coordination.
Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.
Understand member insurance products and benefits, as well as regulatory and NCQA requirements.
Identify cases to be presented at medical rounds and follow up with providers on recommendations to achieve optimal outcomes for members.
Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population.
Other clinical duties as assigned.