RN Case Manager l Registered Nurse l Commercial Care at Blue Cross and Blue shield of Massachusetts, Inc. in Quincy, Massachusetts

Job Description:

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

The RN Case Manager focuses on arranging and coordinating services that a member needs to get well or stay well. The RN 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 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.
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 designated programs: Medicare Advantage, Federal Employee Program, Commercial Care and Medex

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:
- Minimum 3-5 years of direct patient clinical experience, (home care, hospital, or extended care facility)
- Health care professional with active Massachusetts license; Licensure in additional states a plus
- Knowledge of managed care plans and health insurance experience a plus
- Registered Nurse (RN) or other Allied Health professional with active Massachusetts license to practice. Note: any restrictions against a license must be disclosed and reviewed.
- Bachelor's degree preferred in nursing or other allied health field, masters a plus
- Certified Case Manager (CCM) is preferred, required for some roles
- Ability to demonstrate proficiency with multiple Information Technology systems

SCHEDULE OF HOURS:
- Flexibility is required
- Standard working hours are Monday through Friday anywhere from 8am-6pm (Typical shift is 8:30-4:30)
- You may be required to work one evening a week, until 8pm to support our west coast membership
- You may be required to work one Saturday a month to accommodate our member's needs

LocationQuincyTime TypeFull time

.

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.