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Blue Cross Blue Shield of Massachusetts RN Case Manager l Registered Nurse l Federal Employee Program in Quincy, Massachusetts

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

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 Telephonic 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.

RESPONSIBILITIES:

  • Uses clinical tools and information / data review to conduct comprehensive assessments of referred member's needs / eligibility

  • Determines approach to case resolution and creates comprehensive case management plans

  • Evaluates member's benefit plan and available internal and external programs / services

  • Interpretation and application of relevant criteria and guidelines, standardized case management processes, policies, and regulatory standards

  • Educates members on benefits, services, resources, alternative funding, and health care alternatives

  • Utilizes negotiation skills to secure appropriate services to meet the member’s healthcare needs

  • Interacts with treatment providers, PCPs, and physicians as needed to support the plan of care

  • Regularly interacts with supervisors, managers, and physicians to discuss questions and concerns regarding specific cases

  • Presents cases at rounds and follows up with physicians as necessary to obtain physician input and achieve optimal outcomes for our members

  • Monitors for clinical quality concerns and refers appropriately

  • Identifies and escalates quality of care issues through established channels

  • Monitor clinical care services provided to members to optimize clinical outcomes

  • Provides telephone triage, crisis intervention and emergency response as situations arise

  • Utilizes case management and quality management processes in compliance with regulatory guidelines and company policies and procedures

  • Performs regular interventions and interactions with members to maintain the appropriate engagement level based on the course of situation / disease

  • Closes cases in a timely manner while maintaining member satisfaction

QUALIFICATIONS & TRAINING:

  • Ability to adapt and be flexible to change

  • Strong team-work 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/TRAINING:

  • Active Massachusetts RN License is required; other state licenses is a plus. Note: Any restrictions against a license must be disclosed and reviewed

  • Minimum 3-5 years working in either home care, hospital, or extended care facility

  • Must be able to work out of the Quincy, MA office M-F

  • Clinical experience in disease management, complex chronic conditions/co-morbidities is desired

  • Triage experience is desired

  • Bachelor’s degree in nursing is preferred; Associate's degree in nursing will be taken into consideration

  • Certified Case Manager (CCM) preferred or other comparable certification

  • Ability to utilize and demonstrate proficiency with Information Technology systems

SCHEDULE OF HOURS:

  • Flexibility is required

  • Standard working hours are Monday through Friday 8:30 – 4:30pm

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.

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