Clinical Nurse, Case and Disease Management - High Cost Claims

Blue Cross and Blue Shield of Kansas City; Wichita (KS); On-site; USD 60,000 - 80,000; Full time

Job summary

A health insurance organization is seeking a Clinical Nurse to facilitate case and disease management for high-cost claims. This role involves developing care plans, monitoring patient outcomes, and acting as a liaison between members and healthcare providers. Ideal candidates should have a nursing degree, significant clinical experience, and relevant certifications. The position offers a comprehensive benefits package and emphasizes professional development.

Benefits

Paid time off

Tuition reimbursement

401(k) plan

Annual incentive bonus

Employee discount

Qualifications

• Valid and active Registered nurse (RN) in Missouri and Kansas required.
• 3 years of full-time direct patient care clinical experience.
• Case Management Certification within 3 years of hire.

Responsibilities

• Conduct member assessments to develop care plans.
• Act as a liaison between member, employer, and providers.
• Monitor effectiveness of care plans and adjust as needed.
• Educate members on clinical issues and care management.

Skills

Communication skills

Problem-solving

Knowledge of regulations

Team coordination

Education

Associate degree in nursing

Bachelor's degree in nursing (preferred)

Job description

Clinical Nurse, Case and Disease Management - High Cost Claims

parental leave, paid time off, paid holidays, tuition reimbursement, 401(k), employee discount

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:

• 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

Job Description Summary: Utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote optimal, cost-effective outcomes. Transplant only: Provides prior authorization for, coordinates, and individually manages all member transplants. Acts as an internal and external customer resource for interpretation of transplant benefits and transplant-related claim adjudication. Serves as a company expert on current and future transplant types. The candidate for this position must reside in the Kansas City metropolitan area. Job Description

• Completes member assessments by collecting and analyzing information across the seven domains of health and develops and implements individualized care plans with appropriate interventions in a culturally sensitive way. Uses standardized tools to complete assessments in the areas of clinical, functional, financial, support system, psychosocial and cognitive and environmental realms.
• Monitors effectiveness of plan of care by gathering sufficient information from relevant sources in order to intervene, as appropriate, to improve health outcomes. Determines appropriate intervals for monitoring plan of care. Utilizes internal, community and other healthcare resources to maximize outcomes.
• Acts as liaison between member, employer, providers, support system and BlueCross BlueShield of Kansas City. Works with multiple members of the healthcare team to foster continuity and coordination of care.
• Prioritizes interventions based on clinical need and readiness to change. Educates and works with members at different educational and health literacy levels. Utilizes clinical knowledge and critical thinking skills to individualize evidence based interventions. Assesses the member's need for education and tailors teaching to the member's knowledge level and learning style.
• Meets individual quality performance standards and annual targets for program performance as mutually agreed to by management team to maximize program value. Ensures compliance with applicable URAC and NCQA guidelines and state and federal regulations.
• Meets targets for program performance, such as monthly productivity and annual caseload requirements as mutually agreed to by management team to maximize program value.
• Schedules time effectively. Works with minimal supervision. Handles multiple projects simultaneously. Prioritizes work appropriately.

Additional duties for Transplant only:

• Provides prior authorization of the transplant and manages individual member cases. Reviews transplant evaluation and authorizes in accord with medical policy. Opens case and follows NCQA case management standards. Documents transplant authorization, issues authorization letters, and follows in FACETS UM system in accord with UM concurrent review guidelines. Consults with Medical Director on cases outside medical policy, notifies providers and members, if transplant benefits are denied, and explains appeal rights.
• Educates members, providers, and other customers regarding transplant benefits. Directly educates the transplant financial coordinator of the transplant center, member and/or family members, brokers, group and marketing reps, and other providers. Directly educates internal customer service reps regarding individual transplant benefits and the transplant network.
• Ensures proper payment of pre-transplant, transplant, and post-transplant claims. Sets up transplant pre-pay review for each individual claim. Reviews transplant billing packets and reconciles with transplant centers if necessary. Continuously reviews FACETS claim history to determine if claim has been paid or if adjudication problems are occurring. Follows up with member and transplant center during the global payment process to ensure accurate payment. Responds to claims inquiries.
• Accurately reports potential high cost members and tracks costs on members currently undergoing transplants.
• Serves as transplant information source for other departments of the company (e.g., marketing department, senior management, steering committee, contracting department, etc.).

Minimum Qualifications

• Associate degree in nursing
• 3 years full-time direct patient care clinical experience in either of the following: transplant, oncology or medical/surgical
• Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Thorough knowledge of URAC and NCQA guidelines and state and federal regulations.
• Valid and active Registered nurse (RN) in Missouri and Kansas.
• Case Management Certification within 3 years of hire date or within 3 years of transfer to Case Management role/department.

Preferred Qualifications

• Bachelor's degree in nursing with minimum of 5 years' experience, including at least three years' of case management and clinical transplant experience
• Valid and active Registered nurse (RN) licensure in all 50 states and the District of Columbia initiated within 6 months and completed within 15 months of hire date.
• Intermediate level keyboarding skills
• Intermediate level knowledge of FACETS UM, CM and claims applications.
• Experience in working with Health and Wellness and programs or an understanding of wellness principles
• Thorough knowledge of NCQA guidelines and state and federal regulations
• Intermediate level knowledge of Milliman guidelines .

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.