Medicare Advantage Case Management Nurse

Blue Cross & Blue Shield of Kansas, Inc.; Topeka (KS); On-site; USD 74,000 - 107,000; Full time

Benefits offered by this job

Incentive pay (EPIP)

Health, Vision, Dental insurance

Parental leave 6 weeks

Fertility/Adoption support

Caregiver leave 2 weeks

401(k) matching 5%

Tuition reimbursement

Wellness benefits

Job summary

Blue Cross and Blue Shield of Kansas, Inc. is seeking a Medicare Advantage Case Management Nurse Non-Certified/Certified to oversee day-to-day case management activities, review and communicate with members and providers, and negotiate reimbursement.

The role involves ensuring quality of care, collaborating with medical directors, claims, and legal counsel, and supporting precertification and alternative care activities.

Qualifications

• Non-Certified RN with 3+ years clinical nursing experience; BSN preferred.
• Current Kansas RN license required; CCM within 2 years.
• Experience with government programs is helpful.

Responsibilities

• 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.

Education

RN license (KS)

CCM certification

Job description

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.

What you need

• 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.

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.

For more than 70 years, Blue Cross and Blue Shield of Kansas has built a reputation of trust. As we move forward in this new era of health care we want to continue that tradition. Whether a member needs Blue Cross to cover an annual check-up or give them peace of mind during a major medical crisis, we want our members to know they can trust BCBSKS to meet their needs. Our mission: Being the insurer Kansans trust with their health.