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Case Manager, RN

Company: Blue Cross Blue Shield of Rhode Island
Location: Providence
Posted on: July 11, 2018

Job Description:

Job Description Assist members in navigating the healthcare system, ensuring access to evidence-based care. Educate, empower, and coordinate services for members to improve their health and well-being. Facilitate communication between patient, provider, and health plan to ensure members receive the full benefit of integrated care. ESSENTIAL JOB FUNCTIONS: 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 healthcare 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. Exemplify 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. QUALIFICATIONS: Minimum Education and Experience: Unrestricted Rhode Island nursing license. Unrestricted Massachusetts nursing license. Three to five years of experience in a medical/clinical environment or managed health plan. Must obtain Certified Case Manager (CCM) certification within three years of employment. Preferred Education, Additional Qualifications, and Experience: Bachelor's degree in Nursing. Professional nursing certification. Experience working in a managed care/health maintenance organization. Required Knowledge, Skills, and/or Abilities: Knowledge of utilization management and/or coordination of care. Knowledge of population health and chronic condition management principles. Understanding of healthcare 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 and written communication 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. At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, age, national origin or ancestry, disability, veteran status, sexual orientation, genetic information, sex, gender identity or expression, and any other personal attributes protected by federal, state, or local law. For more information about our commitment to diversity and inclusion, please see our Diversity Report at bcbsri.com/diversityreport . The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf to view the "EEO is the Law" poster. BCBSRI is committed to working with and providing reasonable accommodation to individuals with disabilities. If, because of a disability, you need a reasonable accommodation for any part of our application process, please contact us at (see application details) for assistance. During the application process, please allow a minimum of five business days before you contact our office to inquire about the status of your application. If you have any questions regarding your application or during the process, please contact Human Resources by phone at (see application details) or by email at (see application details) . Southern New England, Boston, MA, Hartford, CT, Health Data Analyst, RI Health Insurer, Healthcare, Wellness, Provider, Network, Rhode Island, RI, Care Management, Certified Professional Healthcare Management, CPHM, Certified Case Manager, CCM, Accredited Case Manager, ACM, Utilization Review, Med/Surg, Med-Surg, Med Surg, Medical/Surgical, Medical-Surgical, Medical Surgical, Registered Nurse, RN, Coordinator, Coordinate, BSN, Bachelor's Degree in Nursing

Keywords: Blue Cross Blue Shield of Rhode Island, Providence, Case Manager, RN, Healthcare, Providence, Rhode Island

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