[Hiring] RN Case Manager @Blue Cross Blue Shield of Massachusetts

Role Description

The Clinical Care Manager is responsible for facilitating care for members and families of members who may have rising health risks or complex healthcare needs, to promote optimal health. This position is self-directed and works independently and collaboratively to facilitate care based on the principles of care management. Facilitation is focused on assessing needs, identifying health care disparities, social determinants of health, and any barriers to care.

The Team

The Clinical Care Manager is part of a highly dedicated and motivated team of professionals, including:

• Medical and behavioral health care managers
• Dieticians
• Pharmacists
• Clinicians
• Medical directors

Key Responsibilities

• Engage members in appropriate plans of care, coordinate care and services as appropriate, communicate effectively and provide members with education and resources as needed.
• Promote member compliance with treatment plan, encourage shared decision-making, and set appropriate goals to promote optimal member outcomes.
• Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow and appropriately document comprehensive care management plans.
• Review medication list and educate members with complex pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.
• Successfully connect, engage, and maintain member engagement to support seamless care transitions and optimized health outcomes.
• Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
• Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.
• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.

Qualifications

• Ability to identify and document member-driven, specific, measurable activities that address actionable behaviors and goals.
• Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
• Proficient with multiple IT systems.
• Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.

Requirements

• 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).
• Utilization Management experience, preferred.
• Active licensure in Massachusetts is required, appropriate to position (RN/PT).
• Licensure in additional states a plus.
• Note: Any restrictions against a license must be disclosed and reviewed.

Benefits

• Comprehensive package of benefits including paid time off.
• Medical/dental/vision insurance.
• 401(k).
• Suite of well-being benefits to eligible employees.