RN Case Manager

Arkansas Blue Cross and Blue Shield; Little Rock (AR); On-site; USD 65,000 - 90,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an RN Case Manager to optimize patient care and resource utilization. The role focuses on assessing, planning, implementing, coordinating, monitoring and evaluating comprehensive care plans to meet individual health needs.

The position requires a current RN license in good standing, a certified case manager credential (CCM/ACM or RN-BC) or URAC certification within three years, and a bachelor's degree in nursing preferred.

Qualifications

• RN license with current active state license in good standing; case management certification required.
• If certification is not obtained prior to employment, URAC recognized within three years of hire as an RN Case Manager.
• Acceptable certifications: CCM, ACM, or RN-BC.

Responsibilities

• Assess, plan, implement, coordinate, monitor, and evaluate care for individuals using plan benefits and community resources.
• Other duties as assigned.
• Practice nursing within licensure and adhere to policies, URAC standards and state regulations to ensure patient safety and appropriate level of care.
• Provide education on disease-specific conditions as needed.
• Stay current with medical procedures, products, services and contracts.
• Serve as liaison among patients, families, physicians, hospital discharge planners and home care providers to promote quality and cost-effectiveness.

Skills

Administrative Process

Affinite CM

Affinite UM

CCI Edits

Collaborative Communications

Critical Reasoning

Cross-Functional Planning

Customer Relationship Management (CRM)

Customer Service Workstation

Deductive Reasoning

Five9

Information Security

Interpersonal Relationship Management

Microsoft Excel

Microsoft Office

Microsoft Outlook

Microsoft PowerPoint

Needs Assessment

Oral Communications

Problem Sensitivity

Researching

Sound Judgment

Support Coordination

Written Communication

Education

Bachelor's degree in Nursing

Tools

Five9

Customer Relationship Management (CRM)

Microsoft Excel

Microsoft Office

Microsoft Outlook

Microsoft PowerPoint

Job description

Job Summary

The RN Case Manager plays a critical role in optimizing patient care and resource utilization. The incumbent is responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating comprehensive care plans to meet individual health needs. This role focuses on quality patient outcomes and cost-effective healthcare delivery and may encompass general medical case management or specialize in high-acuity areas and/or high-cost areas such as high-risk obstetrics and neonatal care, chronic disease management, and/or mental health support (excludes Behavioral Health).

Education

Bachelor's degree in Nursing preferred.

Licensing/Certification

Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required. Case management certification required. If certification is not obtained prior to employment, must obtain URAC recognized within three (3) years of hire as a RN Case Manager. The acceptable case management certifications are Certified Case Manager (CCM), Accredited Case Manager (ACM), and Registered Nurse - Board Certified (RN-BC).

Knowledge & Experience

Minimum four (4) years' clinical practice experience in at least one of the following areas: case management, home health, critical care, medical/surgical, discharge planning, concurrent review, or obstetric/neonatal care.

Essential Abilities & Skills

• Independence
• Detail oriented

Skills

• Administrative Process
• Affinite CM
• Affinite UM
• CCI Edits
• Collaborative Communications
• Critical Reasoning
• Cross-Functional Planning
• Customer Relationship Management (CRM)
• Customer Service Workstation
• Deductive Reasoning
• Five9
• Information Security
• Interpersonal Relationship Management
• Microsoft Excel
• Microsoft Office
• Microsoft Outlook
• Microsoft PowerPoint
• Needs Assessment
• Oral Communications
• Problem Sensitivity
• Researching
• Sound Judgment
• Support Coordination
• Written Communication

Responsibilities

• Assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet an individual’s health needs through the use of plan benefits and community resources to facilitate appropriate cost effectiveness and cost containment measures are met.
• Other duties as assigned.
• Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations and makes decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Provides specialized education and knowledge on disease specific conditions as needed and assigned.
• Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery, enterprise procedures, policies and contracts.
• Serves as a liaison facilitating a collaborate process which includes patients, families/caregivers, physicians, hospital discharger planners, home care providers and other ancillary providers to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
• Works proactively with referrals from multiple sources to identify appropriate candidates for case management, explains services ensuring voluntary agreement of services and maintains a minimum patient caseload in a timely matter.

Certifications

• Accredited Case Manager (ACM) - American Case Management Association (ACMA)
• Certified Case Manager (CCM) - The Commission for Case Manager Certification (CCMC)
• Registered Nurse (RN) - Arkansas State Board of Nursing

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.