RN Medex Case Manager l Registered Nurse l Medicare Advantage

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
• 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, FEP, Commercial, and Medex
• Utilization Review Services - Associate will conduct pre-certification, concurrent, and retrospective reviews when indicated and as allowed, for applicable product lines and levels of care, with emphasis on utilization management, discharge planning, coordination of services, clinical outcomes, and quality of services
• Evaluation of member's clinical status, benefit plan /product, and appropriateness for internal and external programs and sites of service in order to facilitate determination of cost-effective, medically necessary plan of care
• Interaction with treatment providers, PCPs, physicians, therapists, and facilities, as needed to gather clinical information support the plan of care
• Regular interactions with case managers, supervisors, managers, and physicians to discuss level of care questions, concerns, discharge needs, and barriers to achieving the most cost-effective, medically appropriate plan of care.
• Presentation of cases at rounds, during on site consultant /account assessments and follow-up with physicians as necessary to obtain physician input and achieve optimal outcomes

QUALIFICATIONS:

• 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 & TRAINING:

• 3-5 years of recent direct patient care experience, (home care, hospital, or extended care facility)
• Active and unrestricted MA RN License, required ; Licensure in additional states a plus
• Open to onsite remote options.
• Knowledge of Medicare plans and/or guidelines is required
• Utilization Review, Case Management, triage and/or telephonic care management experience, highly desired
• Bachelor's degree preferred in nursing; Associate's degree in nursing will be taken into consideration
• Certified Case Manager (CCM) is preferred, required for some roles
• Expert in Microsoft Office Suite programs and other Information Technology systems: JIVA, InterQual, and/or MedHOK experience is a huge plus

SCHEDULE OF HOURS:

• 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

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join our Talent Community to stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.