Blue Cross Blue Shield of Massachusetts RN Case Manager l Registered Nurse l Commercial Care in Quincy, Massachusetts
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The Telephonic RN Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and targeted intervention to promote optimal, cost-effective outcomes.The function of this position is to assist Members in the administration of their health plan benefits. The Telephonic RN Case Manager focuses on arranging or coordinating services that the member needs to get well or stay well and removing 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 demonstrates understanding of the department business objectives and measures. The principles and core technology of case management are applied to members across various product lines, benefits, demographics, conditions, and programs.
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
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:
3-5 years direct patient clinical experience, (home care, hospital, or extended care facility)
Active Massachusetts RN License, required; Licensure in additional states a plus. Note: any restrictions against a license must be disclosed and reviewed
Knowledge of managed care plans and health insurance experience a plus
Bachelor’s degree in nursing, preferred; masters a plus
Certified Case Manager (CCM) is preferred, required for some roles
Ability to demonstrate proficiency with multiple Information Technology systems
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.