Case Manager

Blue Cross and Blue Shield of North Carolina; Tennessee; Hybrid; USD 74,000 - 118,000; Full time

Job summary

Blue Cross NC is seeking a RN Case Manager to join the FEP Case Management Team. The role coordinates care, resources and services for members, conducting comprehensive assessments and developing member-centric plans to achieve optimal outcomes.

The position requires an RN license (NC or compact) and a CCM certification within 2 years, with a hybrid work model and strong emphasis on collaboration across healthcare teams to improve patient care and resource utilization.

Qualifications

• RN with clinical and/or case management experience.
• Valid RN license for NC or compact multi-state licensure.
• CCM certification to be obtained within 2 years of employment.

Responsibilities

• Coordinate care, resources and services to achieve optimal outcomes.
• Perform comprehensive assessments and plan care with members and providers.
• Develop member-centric plans considering health status and support needs.
• Utilize community resources and funding in the plan of care.
• Monitor and adjust plans based on member progress and acuity.
• Evaluate care across the continuum and educate members for proactive care.
• Document all aspects of the plan from assessment to outcome.
• May outreach high risk or high utilization members.
• Review treatment plans and assess benefits/needs for exceptions.
• Develop policies and trainings as needed for internal/external use.

Skills

RN

Case management

Clinical assessment

Care planning

Interdisciplinary collaboration

Member education

Education

RN license (NC or compact multi-state licensure)

CCM certification within 2 years

Tools

EMR systems

Job description

Job Description

We're hiring a Case Manager to join the FEP Case Management Team! Dependent on clinical discipline, the Case Manager coordinates appropriate care, resources and/or services of selected member populations. Provides guidance and promotes effective utilization and monitoring of health care resources to drive quality care for our members. Collaborates as needed with varied members of the healthcare team to achieve optimal clinical and/or resource outcomes.

What You'll Do

• Serve as a team member on a multidisciplinary team, coordinating care, resources and/or services for members to achieve optimal clinical and resource outcomes.
• Utilize applicable clinical skillset and perform comprehensive assessments to determine how to best collaborate with members, family, internal partners and external services/providers on plans for treatment, appropriate intervention and/or discharge planning.
• Develop a member-centric plan tailored to members' needs, health status, educational status and level of support needs; identify barriers to meeting goals or plan of care
• Utilize community resources and funding sources as needed in the development of the plan of care.
• Perform ongoing monitoring and management of member which may include scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity.
• Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care, etc).
• Educate members and encourage pro-active intervention to limit expense and encourage positive outcomes
• Effectively document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome.
• May outreach directly to members identified as high risk, high cost, or high utilization cases.
• May review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible.
• May evaluate medical necessity and appropriateness of services as defined by department.
• As needed, develop relevant policies/procedures, education or training for use both internally and externally.

What You Bring

• RN with 3 years of clinical and/or case management experience required.
• Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.
• Incumbent must obtain Certified Case Manager (CCM) certification within 2 years of employment.

Bonus Points (Preferred qualifications)

• Case Management experience is strongly preferred.
• Maternal health/pediatrics nursing experience is a plus.
• EMR (electronic medical records) experience is preferred.
• Strong technical aptitude and ability to learn new systems quickly.
• Certified Case Manager (CCM) certification preferred.

WhatYou'llGet

• The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community

• Work-life balance, flexibility, and the autonomy to do great work

• Medical, dental, and vision coverage along with numerous health and wellness programs

• Parental leave and support plus adoption and surrogacy assistance

• Career development programs and tuition reimbursement for continued education

• 401k match including an annual company contribution

• Learn more

WhereYou'llWork

Our Hybrid Flex approach is builton presencewith a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplacethat'sflexible, connected, and future focused.

In a Hybrid-Flex role,you'llwork in the office at least two days a week for collaboration and connection. In a Remote Flex role,you'llwork virtually, with a few in-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

$73,698.00 - $117,917.00

Care Plan Development, Care Planning, Clinical Outcomes, Health Care, Healthcare Utilization Management, Nursing Fundamentals, Patient Advocacy, Patient Care, Patient Care Coordination, Patient Evaluations