Resp & Qualifications
NOTE: This positions supports the Medicare Advantage DSNP program.
The RN Case Manager works with the member, the member's family and providers involved in the member's care to coordinate the services and referrals necessary to help reduce preventable hospitalizations and support self-management of their medical care and conditions. The RN Case Manager is responsible for developing a plan of care for the member in conjunction with the member and member’s caregivers, and in collaboration with the member’s PCP and specialist(s). The RN Case Manager will assist in actuating the Plan of Care. This will involve working with the member to close clinical and pharmacy care gaps, mitigating non-clinical barriers to care, and facilitating the coordination of benefits as required. The RN Case Manager will act as a liaison between the member, community-based resources, and health care providers and institutions.
Essential Duties and Responsibilities:
• Provides telephonic Care/Case Management to assigned members of targeted high-risk populations and is available to provide advice per protocols
• Collaborates effectively with the member and family to establish an individualized and successful plan of care, with an emphasis on appropriate services to meet health needs
• Implements the plan of care, monitors compliance, and addresses barriers and challenges that impact the member’s identified goals
• Evaluates member/family strengths, health behaviors, and resources
• Successfully collaborates with member and family to assure comprehension of available resources
• Coordinates with member, family, and caregivers to help resolve barriers to care
• Serves as a resource and educator to the member and his/her family, providing information regarding preventative and wellness care
• Intervenes with at-risk members, on behalf of the member and organization, to reduce avoidable emergency room visits or unnecessary hospital admissions by reducing condition exacerbation
• Monitors member status against appropriate outcomes and addresses clinical issues with the care team.
• Documents all activities in the appropriate system(s) on a timely basis, to include, but not limited to, member self-management measures, mutually agreed upon interventions, and progress or barriers.
• Participates in a regular rotation of after hours on call
• Other duties as assigned
Education, Experience and Qualifications:
• Required to have education, training, or professional experience in medical or clinical practice.
• A current Maryland nursing license without restrictions required
• CCM preferred or a minimum of 2 years of Case Management experience
• In place of CCM or case management experience, will consider 3-5 years of clinical nursing experience in medical-surgical, community/home health care, case management, or equivalent experience reviewing patient medical care and services in one or more of the following specialty fields:
o High risk diseases and comorbidities (e.g. diabetes, hypertension, COPD, CHF, asthma)
o Complex Medical Illnesses (e.g. HIV/AIDS, ESRD, Oncology)
o Palliative Care/Hospice
• In-depth knowledge of current standards of medical practice and insurance benefit structures to facilitate medical review decisions and interpret contract benefits and managed care guidelines
• A strong knowledge of Case Management process, standards, and understanding of managed care in all lines of business.
• Detailed knowledge and competency in all types of medical necessity decisions, including inpatient care, subacute/skilled care, outpatient care, hospice care, and home health care
• A strong knowledge and expertise in case managing complex cases with minimal supervision
• Health Plan experience is a plus
• BSN preferred
Knowledge, Skills and Abilities:
• Ability to effect change, perform critical analysis and promote positive outcomes, and facilitate empowerment for the member/family
• Provide excellent customer service to external and internal customers
• Knowledge and competency in all types of medical necessity decisions, including in patient care, sub-acute/skilled care, outpatient care, hospice care, and home health care
• Excellent analytical and problem-solving skills to judge medical necessity and appropriateness of patient services and treatments on a case by case basis
• Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
• Ability to make decisions on what needs to be done based on clearly established guidelines
• Exceptional communication skills, both written and oral, with the ability to positively influence others with respect and compassion; Spanish language ability is desirable
• Substantial knowledge of Microsoft Office including SharePoint, Outlook, Excel and Word, PowerPoint
• Proficiency in medical management software utilized for utilization review, medical appeals, and case management preferred
Department: MD Medicaid -HEALTH SERVICES
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 4.8.21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship