RN Case Manager - DSNP

Schedule: Hybrid

Compensation: $73,500 - $110,300

Jump into the new world of health insurance:

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.

Join others who know diversity is strength:

We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.

Why this job matters:

Direct and coordinate the beneficiary's care. Complete the HRA with the D-SNP member and/or the comprehensive assessment, coordinate care across the health care continuum, coordinating benefits, managing the members of the ICT, and developing and maintaining the ICP. Responsible for taking the problems/barriers from the HRA and incorporating into the ICP. Educate the beneficiary and/or caregiver on self-management strategies and skills. Collaborate with other team members, providers, community agencies and caregivers/ natural supports to facilitate the development of the ICP. Work closely with the health navigator to support self-management activities and the associated SMART goals. Facilitate communication among the beneficiary, providers, health plan, and others who participate in the beneficiary's care. Provide consultation and support to the Behavioral Health Care Manager and other members of the ICT to support integrated care management delivery.

What you will do:

• Manage members through the healthcare delivery system; assess needs in order to identify appropriate interventions. Conduct telephonic or face to face health assessments to identify high risk or emerging risk members who would benefit from education and intervention. Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the members' total health.
• Identify opportunities to impact claims expense trends for the all lines of business/or at the individual member level.
• Evaluate action plans by working with members, and collaborating with providers. Modify action plans as necessary.
• Monitor and evaluate patient services to ensure appropriate coordination of care. Collaborate with the Utilization Review process including pre-authorization, concurrent review, screening cases for quality of care issues, and discharge planning.
• Promote member and provider satisfaction by demonstrating working knowledge of member benefits, including but not limited to health, disability, Employee Assistance or other plans/benefits available to the member
• Provide continuity and consistency of care by building positive relationships between the member and family, physicians, provider, care coordinator, and health care plan.
• Work collaboratively with the team and others necessary to develop and implement solutions. Identify barriers to performing job duties as well as opportunities for improvements. Exemplifying the corporate values in action through accountability, collaboration, integrity and respect in maintaining a high performance culture.
• Participate in department initiatives and projects. Perform other duties as assigned.

What you need to succeed:

• A combination of education and related work experience
• Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC)
• Three to five years' experience in a medical/clinical environment or managed health plan
• Expertise working with D-SNP beneficiaries
• Must obtain Certified Case Manager (CCM) certification within three years of employment*
• Knowledge of utilization management and/or coordination of care
• Knowledge of population health and chronic condition management principles
• Understanding of health care delivery system access points and services
• Ability to navigate the healthcare delivery system
• Good business acumen
• Knowledge of business process improvement techniques and strategies
• Excellent verbal, written communications and technical skills
• Negotiation skills
• Presentation skills
• Decision-making skills
• Good problem solving skills
• Ability to interface with employees at all levels
• Ability to effectively navigate ambiguous situations with limited direction
• Excellent organizational skills and ability to successfully prioritize multiple tasks
• Ability to handle multiple priorities/projects
• Strong time management skills

*Applies to positions working with FEP product only

The extras:

• Professional nursing certification
• Experience working in a managed care/health maintenance organization
• Experience working with the Duals and/or Medicaid population
• Bilingual