Blue Cross Blue Shield of Massachusetts RN Case Manager l Registered Nurse l Case Management in Quincy, Massachusetts
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The 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 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 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.
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
Will need to understand regulatory requirements for Commercial Care
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 3-5 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, VNA, home care, and/or extended care facilities
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
LocationQuincyTime TypeFull time
Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power , Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.
Our Commitment to You
We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.
Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.
Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.