RN - Clinical Account Manager, High-Cost Claimants

Blue Cross and Blue Shield of Kansas City • Kansas, IL

4d • Hybrid

About The Position

This Registered Nurse presents data-driven insights and clinical health information to large self-funded client groups and insurance brokers/consultants to identify those members that are high-cost or potentially high-cost claimants as quickly as possible. Understands Blue KC healthcare programs, benefits and services, medical policy, provider network/reimbursement strategies, and industry best practices to positively impact medical cost trends. The candidate for this position must reside in the Kansas City metropolitan area.

Requirements

• RN, BSN with a minimum of 3 years of experience
• Previous Case Management Experience required
• CCM Required within 3 years of hire

Nice To Haves

• Advanced degree
• Previous experience with Health Plan

Responsibilities

• Partner with account team members to provide best-in-class member and client service.
• Educates clients, brokers, consultants, and internal associates and articulates the value of Blue KC's approach to managing care delivery to the employer groups.
• Serves as a key subject matter expert and strategic partner for the Commercial Sales organization and regularly attends client meetings (with benefits managers and executives) to review health outcomes and cost information.
• Actively monitors care management identification and segmentation results, engagement rates, and Performance Guarantees to address any issues identified.
• Completes the requests of the internal and external stakeholders promptly, addressing key stakeholders' needs with a sense of urgency, prioritization, reprioritization, and flexibility to meet business needs.
• Contacts Strategic Client Consultants to discuss special member situations and determine if an exception or special consideration (e.g., benefits) should be made.
• Participate in existing client utilization and renewal meetings or tell our clinical value story as requested.
• Track, monitor, and identify clinical metrics for client population, and work with stakeholders to mitigate as appropriate.
• Leverage various clinical reports (e.g., High-cost claimant reports, early warning reports, census reports, case management participant reports, etc.) to identify potential high-cost claimants, opportunities for member engagement, and ensure the member is in the correct place within the care management continuum.
• Expert at reviewing and presenting population health information, ability to investigate large employers' high-cost utilizers as well as key cost drivers from a clinical perspective
• Communicates the value Blue KC offers using data from the member/employer group perspective.
• Provide time-sensitive clinical reporting on requests for employer groups received by standard request processes for Case Management (CM) from Underwriting, client managers, sales team, brokers, etc.
• Collaborates with the Clinical Operations leadership team to develop strategies and identify adjustments needed to meet established goals.
• Collaborates with the Senior Healthcare Consultants, Strategic Client Consultants, Onsite nurses, Wellness Coordinators, and key personnel from Employer Groups to provide monthly and/or quarterly reporting to the Employer Group to monitor trends and ensure targets and expectations are met.
• Collaborates with Underwriting by completing ad hoc reporting requests that include providing clinical summary and details on the projection of future costs to analyze underwriting risk.
• Collaborates with Medical Directors, Pharmacists, Behavioral Health, and nurses during rounds sessions discussing high cost, high length of stay, high-cost drug management, and opportunities for steerage to a lower-cost plan of care.
• Oversee program and group implementations for assigned groups, RFP responses, internal and external client audits, program presentations for clients, and program materials creation and maintenance.
• Participates in cultural trainings to review the Case Management program, engagement techniques, cost containment strategies, and opportunities for collaboration with employer's health clinics/staff
• Communicates and co-leads Employer Group/Broker meetings reviewing early warning reports and high-cost claimant data on cost drivers, future cost projection, case management engagement, and interventions for cost containment.
• Regular communications with Blue KC Clinical Operations staff to ensure identified members are addressed as needed.
• Keep Population Health leaders and team members abreast of all employer group information, including incentives, penalties, unique workflows, employer group wellness offerings, and/or benefit updates.
• Build and manage strong client and third-party relationships.
• Support general business needs and operations, as required.
• Ability to resolve numerous and undefined issues requiring detailed information gathering, analysis, and investigation to understand the problem; difficult and moderately complex problems typically impact multiple departments or specialties and are usually solved through drawing from prior experience and analysis of issues.
• Develops new perspectives and innovative approaches to existing problems.
• 5% or more travel to client and business meetings.
• Remote working opportunities when not at client or business meetings.

Benefits

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
• Annual incentive bonus plan based on company achievement of goals
• Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities, and tuition reimbursement program
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees