Medicare Advantage Case Manager Nurse (Hybrid)

Blue Cross & Blue Shield of Kansas, Inc.; Topeka (KS); Hybrid; 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

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.