RN Manager, Case Management

Blue Cross Blue Shield of Massachusetts; Hingham (MA); On-site; USD 105,000 - 128,000; Full time

Benefits offered by this job

Medical/dental/vision insurance

401(k)

Paid time off

Well-being benefits

Job summary

Blue Cross Blue Shield of Massachusetts is seeking an RN Manager to lead the case management and utilization management team, drive policy execution, and develop staff while monitoring group metrics.

You will oversee operations, ensure quality, coordinate with diverse teams, and manage performance with a focus on cost, risk, and regulatory compliance to improve member outcomes.

Qualifications

• Active licensure in Massachusetts (RN)
• BSN required; master's preferred
• 3-5 years RN supervisory/management experience
• Knowledge of case management/utilization management processes
• Strong communication, problem-solving, and negotiation skills
• Proficiency with IT systems
• Bilingual a plus

Responsibilities

• Lead and oversee the CM/UM team, executing policies and procedures
• Monitor and achieve group metrics related to cost and risk
• Mentor and develop CM/UM staff; manage performance
• Ensure knowledge of clinical areas and member populations
• Build relationships with internal and external stakeholders
• Interpret complex medical information for actionable outcomes
• Track and report performance metrics to leadership
• Conduct audits to ensure productivity and address gaps
• Support ad-hoc projects from senior management
• Maintain adherence to performance metrics and continuous improvement

Skills

RN supervision

Case management

Utilization management

Operations leadership

Staff development

Policy interpretation

Performance management

Communication

Mentoring

Budget & cost awareness

Education

Massachusetts RN licensure

BSN required; MSN preferred

Job description

Ready to help us transform healthcare? Bring your true colors to blue.

The Role

The RN Manager will be leading and overseeing a case management/utilization management team, including but not limited to: operations, executing policies and procedures, and provide associate development and performance management. The RN Manager is responsible for monitoring and achieving group metrics, such as cost and risk and ensuring continuous quality and improvements.

The Team

Key Responsibilities

• Implement strategic and operational goals for the CM/UM group; implement and monitor supporting plans
• Oversee the CM/UM group, providing group communications and issue escalation / resolution support
• Maintain awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population
• Serve as a mentor and advisor to CM and UM’s as they work through complex or particularly unique cases
• Become an expert of BCBSMA’s products, benefits, healthcare delivery system, accreditation, regulatory requirements, and community resources
• Interpret, evaluate, and clearly document complex medical information using a directive and focused approach in order to identify relevant and actionable conditions, circumstances, and behaviors
• Meet deadlines, and deliver expected outcomes with appropriate sense of urgency
• Build effective relationships internally and externally, in person and virtually, in order to facilitate professional and business goals
• Effectively negotiate clinical operations environment; Manages clinical and non-clinical resources effectively (e.g., cost, productivity)
• Maintain knowledge of all clinical areas and specific member population
• Responsible for staff management and development including, recruiting and rewarding staff, setting performance expectations, and assessing, monitoring, and counseling staff regarding individual performance
• Articulate performance expectations and establish ongoing training programs for case management associates to achieve these expectations
• Provide management and direction to ad-hoc projects requested by senior management
• Track, analyze, interpret, and report regularly to leadership on case management group performance metrics
• Conduct audits to ensure productivity and performance are meeting or exceeding performance expectations; implement plans to address performance gaps
• Adherence to program, departmental and organizational performance metrics
• Foster clinical excellence by promoting and participating in educational opportunities

Key Qualifications

• Managing in a Clinical Operations Environment (manages clinical and collaborates with non-clinical resources effectively;facilitates staff and team engagement in and accomplishment of clinical, business, and service goals in order to achieve organizational objectives)
• Knowledge of specialized subject matter (demonstrates the use of the right resources and application of the correct policies in order to support clinical determinations and administration of benefit based on product, segment, account, and clinical specialty program needs and objectives)
• Focus (ability to identify and manage to key, high-leverage information, tasks, and events)
• Consistency (ability to facilitate staff adherence to identified workflows, plan requirements, clinical guidelines, to drive sound, objective decisions)
• Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives)
• Call management (ability to structure staff workflows that drive telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional)
• Clinical Management (ability to design workflows, identify processes, and facilitate consultative discussions that enable team members to conduct clinical assessment, clinical review, and management of an end to end episode of care)
• Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities)
• Comfort and proficiency with the use of computers and technology (ability to navigate computer applications quickly and effectively, key in data proficiently in real time during phone calls, work effectively with the phone system, and quickly learn, and effectively work in, a variety of media)

Education And Experience

• Active licensure in Massachusetts is required, appropriate to position (RN, PT, CCM, LICSW, LMHC, BCBA) Licensure in additional states a plus; any restrictions against a license must be disclosed and reviewed.
• For Registered Nurses Only: A Bachelor’s degree in nursing (BSN) is required; Master’s degree, preferred.
• Minimum 3-5 years of RN supervisory and/or management experience, desirable
• Knowledge in the case management/utilization management process, programs, services, business implications, trends, and policies
• Critical thinking & problem-solving skills
• Adaptability, flexibility, and self-discipline
• Exceptional communication, writing, presentation, and negotiation skills
• Proficiency with Information Technology systems
• Bilingual, a plus

Minimum Education Requirements

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full time

Salary Range

$104,580.00 - $127,820.00

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so we encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.