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The telephonic RN Case Manager focuses on arranging and coordinating services that a member needs to get well or stay well. The telephonic Case Manager also works to remove barriers that prevent the member from engaging in an appropriate plan of care. The telephonic RN Case Manager demonstrates strengths working independently as well as collaboratively within a highly matrixed environment.
The telephonic RN Case Manager will be working with a team of other dedicated and compassionate nurses and providers to help meet department business objectives and measures. The RN Case Manager will be using a member-centric, collaborative process involving assessment, planning, targeted intervention, and advocacy, for our members. The telephonic RN Case Manager will work with the member to identify options and services that meet their specific health needs through the health care continuum to promote optimal, cost-effective outcomes.
***This position is eligible for the following personas: Resident, Mobile or eWorker***
KEY RESPONSIBILITIES:
Assess and evaluate member or family support needs by using various data tools and resources
Assist members and their families in the administration of their health plan benefits, promote medication compliance, coordinate care with treatment providers, PCP's and other providers including VNA providers
Assist the member in shared decision-making and goal setting
Collaborate within a team of professionals (supervisors, managers, account representatives, member service associates, and physicians) to provide care coordination appropriate for members
Interpret and apply case management criteria, processes, policies, and applicable regulatory standards
Interact with treatment providers, PCPs, and physicians as needed to support the plan of care
Monitor for clinical quality concerns and refers appropriately
Provides telephone triage and crisis intervention when situation warrants, collaborating with utilization management peers when appropriate
QUALIFICATIONS & SKILLS:
Ability to adapt and be flexible to change as priorities within this environment change constantly
Strong computer skills as multiple computer systems are utilized
Willingness to learn new skills from both a business and clinical perspective
Strong teamwork and communication skills as well as ability to be self-directive
Ability to analyze information to construct effective solutions
Execution and results (ability to set goals, follow processes, meet deadlines, and deliver expected outcomes with appropriate sense of urgency)
Cultural competence (demonstration of awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population)
Clinical assessment (ability to 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)
Care planning (ability to identify and clearly document member-driven, specific, measurable activities that address actionable conditions, circumstances, and behaviors in order to improve health outcomes and cost-effectiveness of services)
Member collaboration and engagement (ability to secure and maintain the motivation, participation, and collaboration of all relevant parties in a purposeful plan to improve health outcomes and cost-effectiveness of service delivery)
EDUCATION & RELEVANT EXPERIENCE:
Minimum 3+ years working as a Registered Nurse and have worked in one or more in the following settings within the last 12 months: medical-surgical unit, critical care unit, telemetry unit, sub-acute setting, VNA, home care, and/or extended care facilities. Experience required in high risk pregnancy population. Experience with IVF population, is preferred.
Active Massachusetts RN License is required. Licensure in additional states, a plus. Please Note: Any restrictions against a license must be disclosed and reviewed
Demonstrated knowledge working with Microsoft Word, Outlook, PowerPoint, and Excel
Managed care plans and health insurance experience is a plus
Bachelor's degree in nursing, is preferred
Certified Case Manager (CCM), is preferred
Minimum Education Requirements:
High school degree or equivalent required
Location
Quincy
Time Type
Full time
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).
Blue Cross Blue Shield of Massachusetts, has a COVID-19 vaccination requirement for building entry. Your offer of employment is dependent upon either being fully vaccinated for COVID-19, or receiving an eworker exemption and/or accommodation based on a disability or sincerely held religious belief, practice, or observance by submitting a request to Human Resources.
