Medicare Advantage Case Management Nurse

Blue Cross Blue Shield of Kansas; Topeka (KS); Hybrid; USD 74,000 - 107,000; Full time

Benefits offered by this job

Health/Vision/Dental insurance

6 weeks paid parental leave

Fertility/Adoption assistance

2 weeks paid caregiver leave

401(k) plan matching up to 5%

Tuition reimbursement

Health & fitness benefits

Job summary

Blue Cross and Blue Shield of Kansas is hiring a Medicare Advantage Case Management Nurse, Non-Certified or Certified. The role manages day-to-day case review, processing, and communications with members and providers, plus primary negotiation on reimbursements.

Training onsite for ~4 weeks; afterwards, hybrid or onsite work per Telecommuting Policy. Must reside in Kansas or Missouri or be willing to relocate.

Qualifications

• RN with a minimum of three years of clinical nursing experience; BSN preferred.
• Current unrestricted Kansas RN license required.
• Must become CCM certified within two years of assuming the position.
• Experience with government programs is helpful.
• Non-Certified or Certified case manager credentials accepted with required experience.

Responsibilities

• Perform case management in compliance with URAC CMS guidelines and CCMC standards.
• Coordinate case management inquiries across departments and vendors.
• Develop and monitor cost-effective treatment plans across providers and settings.
• Provide clinical support for precertification, case management, and alternative care activities.
• Deliver onboarding, training, and guidance to new team members.
• Maintain caseload with timely documentation and follow-up on care plans.

Skills

Effective communication

Analyze and plan

Self-direction

Handle sensitive issues

Discuss reimbursement

Flexible schedule

Education

BSN preferred

RN license (Kansas)

CCM certification within 2 years

Job description

Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

Why Join Us?

Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.

Family Comes First: Total rewards package that promotes the idea of family first for all employees.

Paid vacation and sick leave with paid maternity and paternity available immediately upon hire

Professional Growth Opportunities: Advance your career with ongoing training and development programs.

Dynamic Work Environment: Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.

Trust and Stability: Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.

Inclusive Work Environment: We pride ourselves on fostering a workplace where everyone is valued and respected.

Benefits & Perks

• Base compensation is only one component of your competitive Total Rewards package
• Incentive pay program (EPIP)
• Health/Vision/Dental insurance
• 6 weeks paid parental leave for new mothers and fathers
• Fertility/Adoption assistance
• 2 weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
• Health & fitness benefits, discounts and resources

Job Summary

The Medicare Advantage Case Management Nurse Non-Certified/Certified is primarily and independently responsible for the day-to-day operations of reviewing, processing, and communicating with members and providers involved in case management activities which may include determining appropriateness and cost effectiveness of care in light of quality-of-care objectives. This position serves as primary negotiator with medical providers/vendors regarding reimbursement and provider write off of services involved in specific managed care cases. Also carries primary responsibility for pre and post-case management claim payment. Provide backup support for precert activities. Responsible for performing all activities within State, URAC, HIPAA, DOL, CMS, and MTM goals or guidelines. Training will be onsite for about 4 weeks. After training is completed, this position is eligible to work hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

What you'll do

• Perform case management in compliance with URAC standards, CMS regulations, Kansas Nurse Practice Act, CMSA Standards of Practice, and CCMC guidelines, ensuring accurate documentation, activity monitoring, and audit reporting.
• Coordinate and communicate case management inquiries across departments, including medical directors, customer service, claims, sales, provider relations, behavioral health vendors, and legal counsel.
• Develop, implement, and monitor cost-effective treatment plans that meet patient needs and quality standards, coordinating care across multiple providers and care settings, and negotiating reimbursement when appropriate.
• Provide clinical support for precertification, case management, and alternative care activities for commercial business lines.
• Deliver onboarding, training, and guidance to new team members, and participate in multidisciplinary case management decision meetings involving patients, providers, caregivers, and facility representatives.
• Maintain an appropriate caseload, ensuring timely documentation, follow-up, and continuous evaluation of care plans for effectiveness.

Knowledge/Skills/Abilities

• Ability to communicate effectively, verbally, in writing and via telephone regarding sensitive and confidential issues and maintain a positive professional image.
• Ability to assess, analyze, plan, and evaluate situations.
• Ability to self-direct, make independent decisions, and prioritize daily activities.
• Ability to handle sensitive situations in a positive, professional manner.
• Must be comfortable discussing reimbursement/financial arrangements.
• Schedule could require alternative work hours, which may include evenings, weekends, availability 365 days per year.

Education and Experience

• Non-Certified Registered nurse with minimum three years clinical nursing experience, acute medical/surgical preferred, Bachelor of Science in Nursing (BSN) preferred.
• Current unrestricted Kansas RN license required.
• Must become CCM certified within two years of assuming the position.
• Experience with government programs is helpful.
• Certified Registered nurse with minimum three years clinical nursing experience, acute medical/surgical preferred, Bachelor of Science in Nursing (BSN) preferred.
• Current unrestricted Kansas RN license required.
• Current unrestricted Certification as a case manager (CCM) required.
• Experience with government programs is helpful.

Physical Requirements

90-95% of daily activity requires use of computer and/or telephone.

Compensation

• Non-Certified: $73,920 - $92,400 annually (Exempt Grade 15)
• Certified: $85,600 - $107,000 annually (Exempt Grade 16)

Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.

Our Commitment to Connection and Belonging

At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of connection and belonging, where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law.

Blue Cross and Blue Shield of Kansas conducts pre-employment drug screening, criminal conviction check, employment verifications and education as part of a conditional offer of employment.