Clinical Nurse, Federal Employee Program Case Manager

1 month ago

Wichita, United States Blue Cross and Blue Shield of Kansas City Full time
Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:
  • Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
  • Annual incentive bonus plan based on company achievement of goals
  • Time away from work including paid holidays, paid time off and volunteer time off
  • Professional development courses, mentorship opportunities, and tuition reimbursement program
  • Paid parental leave and adoption leave with adoption financial assistance
  • Employee discount program
Job Description Summary: Utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meeting an individual's health needs through telephonic and digital communication while providing resources to promote optimal, cost-effective outcomes. Job Description
  • Manages a complex and disease management caseload (combined telephonic and digital) through a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote member safety, quality of care and cost-effective outcomes.
  • Completes complex and disease management assessments by collecting and analyzing health information and collaborates with the member to develop and implement individualized care plans with appropriate interventions in a culturally sensitive way. Uses standardized tools to complete assessments addressing clinical support and social determinants of health needs.
  • Conducts comprehensive transitions of care assessments within the specified time frame to effectively transition to appropriate disease and complex care management programs for further engagement and support. Ensures health maintenance is achievable and mitigates risk of readmission by confirming discharge instructions are successfully implemented, medications reviewed, and disease management education provided and prepares the member for future health maintenance and treating physician communication.
  • Acts as liaison between member, providers, FEPDO, support system and BlueKC.
  • Reviews, authorizes and inputs authorization requests for extension of benefits.
  • Reviews, authorizes, and inputs UM authorization requests for Skilled Nursing Facility (SNF) stays and hospice requests.
  • Manually coordinate claims with operations team for hospice, SNF and flexible benefit option (FBO).
  • Tracking of benefits in FEP Direct. This includes SNF, Residential Treatment Center (RTC), Gender Affirming Surgery (GAS), Applied Behavioral Analysis (ABA) and Transplant.
  • Input of data for benefits utilized in FEP Direct for correct payment of claims.
  • Tracking of FBO created in FEP Direct with separate input of cost benefit analysis.
  • FEP CM will case manage both FEP Primary members and Medicare primary members.
  • Required to attend all FEP Care management meetings, town hall calls, FEP Colleges (updates within FEPDO) in addition to all internal Blue KC meetings.
  • Run testing in FEP Pilot programs
  • Engages members to assess preventive and chronic care gaps in care. Prioritizes interventions based on clinical need and readiness to change. Utilizes clinical knowledge and critical thinking skills to individualize evidence-based interventions and tailors teaching to member's knowledge level and learning style.
  • Enrolls new complex members monthly for case management services and initiate the complex assessment and appropriate care plans per NCQA guidelines. Identifies and resolves barriers that hinder health by facilitating patient access to appropriate services, discuss/resolving medication adherence, and educating member on self-care and self-monitoring.
  • Meets individual quality performance standards and annual targets for program performance to maximize program value. Ensures compliance with applicable NCQA guidelines and state and federal regulations. Meets targets monthly performance metrics, such as productivity and caseload requirements to maximize program value.
  • Performs other duties as required.

Minimum Qualifications:

  • Associate degree in nursing.
  • 3 years full-time direct patient care clinical experience in the following: inpatient acute care setting; medical/surgical; transitions of care; discharge planning, home health, case management
  • Comfortable case managing members of all ages and various disease states and health conditions
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the community
  • Ability to define problems, collect data, establish facts, and draw valid conclusions
  • Knowledge of NCQA guidelines and state and federal regulations
  • Valid and active Registered Nurse compact licensure in Missouri and/or Kansas
  • Case Management Certification within 3 years of hire date or within 3 years of transferring into the Case Manager role
  • Membership of local Case Management Society of America (CMSA) Chapter.
  • Beginner level knowledge of and ability to use Microsoft Windows and Microsoft Office applications such as Word, Excel and Power Point

Preferred Qualifications:

  • Bachelor's degree in nursing with minimum of 5 years chronic disease/acute care direct patient care experience including at least 3 years of case management experience.
  • Intermediate level keyboarding and system operational experience and skills
  • Intermediate level knowledge level of FACETS claims processing
  • Working knowledge of FEP Direct and FEP Care Coordination Portal
  • Experience in working with Health and Wellness programs or and understanding of wellness principles
  • Thorough knowledge of NCQA guidelines, HEDIS measures, Gaps in Care, and Social Determinants of Health needs.
  • Current certification as Certified Case Manager

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.

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