Case Management RN

Bcbsla; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Blue Cross and Blue Shield of Louisiana is seeking a Case Manager to assess, plan, implement and evaluate options to meet members’ healthcare needs. The role collaborates with providers and community resources to promote quality outcomes and cost efficiency.

The candidate will use strong communication and analytical skills, maintain privacy, and work within regulatory and accreditation standards to support member care across the continuum.

Qualifications

• Bachelor's degree in nursing, business administration, healthcare or a related field is required.
• 4 years of related experience can be used in lieu of a Bachelor’s degree.
• 2 years of direct patient care/clinical experience required.
• Active and unencumbered RN license to practice in Louisiana is required; multi-state license preferred and must be obtained within 6 months from date of hire.

Responsibilities

• Assess member status by collecting information to identify needs and develop a comprehensive case management plan.
• Develop and implement objectives, goals, and actions with time-specific indicators.
• Advocate for member/family while maintaining privacy and safety across the continuum of care.
• Coordinate with providers, payors, employers and community resources to organize necessary services.
• Assist with return to work, vocational development, and life care planning.
• Participate in quality improvement projects and data collection.

Skills

Communication skills

Analytical skills

Decision making

Work independently

Research and analysis

Office software

Education

Bachelor's degree in nursing/healthcare

RN license (Louisiana)

Multi-state Compact RN license

Tools

MS Office

Job description

POSITION PURPOSE

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 case manager 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.

NATURE AND SCOPE

This role does not manage people. This role reports to this job: MANAGER, POPULATION HEALTH.

Necessary Contacts

• Benefits Administration
• Medical Director
• Underwriting
• Group leaders
• Delegated Vendors
• Legal Department and other employees as needed
• physicians/staff
• hospital administrators/staff
• providers
• caregivers
• subscribers
• community resources

QUALIFICATIONS

• Education: Bachelor's in nursing, business administration, healthcare or a related field is required. RN license can be used in lieu of Bachelor's degree.
• Four years of related experience can be used in lieu of a Bachelor’s degree.
• Work Experience: 2 years of direct patient care/clinical experience required.
• Skills and Abilities: Ability to research and analyze contracts/cases and make appropriate quality and cost effective decisions. Strong communication skills, including the ability to effectively explain/present claims information and procedures to persons with varied levels of insurance/benefits understanding. Excellent organizational and analytical skills. Ability to make decisions, prioritize, find solutions, and work independently. Working knowledge of related software and office equipment.
• Licenses and Certifications: Active and unencumbered (current and unrestricted) RN license to practice in Louisiana is required. Multi-state Compact RN license is preferred. Multi-state Compact RN license is required within 6 months from date of hire. RN license in noncompact state is preferred. May be required to obtain additional RN licensure in noncompact state within 6 months from date of hire. Certified Case Management Certification is preferred. Certified Case Management Certification is required within 3 years from date of hire.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Assess member’s status by collecting in-depth information in culturally competent and confidential manner, about the member’s situation and functioning to identify individual needs in order to develop and implement a comprehensive case management plan that will address needs for moderated to high risk cases.
• 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 specific interventions and evaluate effectiveness that will lead to accomplishing the goals established in the plan.
• Experienced in behavioral interviewing techniques.
• 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.
• Assist with return to work, vocational development, and life care planning.
• Responsible for meeting annual targets for program performance as mutually agreed to by management team to maximize program value.
• Participates in quality improvement projects and data collection to determine the effectiveness of the case management program.
• Participates on project workgroups.
• 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 standard clinical guidelines such as milliman care guidelines, as part of management of complex case management cases.
• Conduct case conferences with member, provider, and facilities as appropriate.
• May provide guidance to less experienced nurses.
• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting.

Work Location

Residency in or relocation to Louisiana is preferred for all positions.

Employment Information

Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity.

Accommodation for Disability

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact [e-mail] for assistance.

Background Checks

We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Drug Free Workplace

A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results. Additionally, we are a Drug Free Workplace.

Company Mission

To improve the health and lives of Louisianians.

Company Vision

A better state of health through preventative, easier and more affordable healthcare.

About Blue Cross and Blue Shield of Louisiana

Blue Cross and Blue Shield of Louisiana (Louisiana Blue) is incorporated as Louisiana Health Service & Indemnity company and is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross and Blue Shield of Louisiana is licensed to sell products only in the state of Louisiana.