We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.
Residency in or relocation to Louisiana is preferred for all positions.
POSITION PURPOSE
Responsible for organizing, coordinating, and providing care coordination and case management services to members who are most at risk for health deterioration, sentinel events, and/or poor outcomes. Manage acute and chronically ill members to improve health and financial outcomes through analysis of needs, design, and delivery of interventions. Utilize a collaborative process to assess, plan, implement, monitor, and evaluate options and services required to meet the member’s healthcare needs. Through communication, the nurse will identify available resources to promote quality, cost effective outcomes. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.
NATURE AND SCOPE
This role does not manage people
This role reports to this job: Manager, Population Health
Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Benefits Administration, Medical Director, Underwriting, Group leaders, Delegated Vendors, Legal Department and other employees as needed, physicians/staff, hospital administrators/staff, providers, caregivers, subscribers, community resources.
QUALIFICATIONS
Education
Diploma in nursing or Associate’s in nursing or Bachelor's in nursing required.
Work Experience
3 years of recent direct patient care/clinical experience is required.
2 years of experience in managed care is preferred.
Experience in the use of behavioral interviewing techniques and theory is preferred.
Skills and Abilities
Requires the ability to prioritize, work independently and anticipate needs to make decisions.
Ability to plan, implement and evaluate appropriate healthcare services in conjunction with a physician treatment plan and evaluate the effectiveness of alternate care services are required.
Requires the ability to research and analyze contracts/cases and make appropriate quality and cost effective decisions.
Knowledge of standardized code sets and medical terminology is required.
Must demonstrate excellent interpersonal, organizational, analytical, and telephonic skills.
Must demonstrate strong communication skills, including the ability to effectively explain/present claims information and procedures to persons with varied levels of insurance/benefits understanding.
Requires working knowledge of related software and office equipment.
Licenses and Certifications
Active and unencumbered(current and unrestricted) RN license to practice in Louisiana is required.
Multi-state Compact RN license is preferred.
Multi-state Compact RN license is required within 6 months from date of hire.
RN license in noncompact state is preferred.
May be required to obtain additional RN licensure in noncompact state within 6 months from date of hire.
Certified Case Management Certification is preferred.
Certified Case Management Certification is required within 3 years from date of hire.
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
In a culturally competent and confidential manner, assess member’s status by collecting in-depth information about the member’s situation and functioning to identify individual needs in order to develop and implement a comprehensive case management plan.
Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators. The case manager will act as an advocate for the member/family, maintaining privacy, confidentiality and safety, building relationships with all relevant parties, supporting informed decision making and facilitating access to necessary and appropriate healthcare services across the continuum of care.
Implement a comprehensive case management plan.
Implement specific case management activities and/or interventions and evaluate effectiveness that will lead to accomplishing the goals established in the case management plan.
Coordinate by collaborating with the member/family, providers, third party payors, employers and community resources in order to organize, integrate, and modify the resources necessary to accomplish the goals.
Interacts with patients and/or providers in order to determine patient care needs, compliance and effectiveness with planned interventions and conduct case conferences as appropriate.
Evaluates the case management plan’s effectiveness in reaching desired outcomes and goals. Modifies any or all of the case management plan’s components if necessary.
Utilizes behavioral interviewing techniques.
Familiar with guidelines and requirements for authorizations of services related to coordination of care for complex cases. Proficient in care management authorization processes, including usage of evidence-based guidelines, as part of management of complex case management cases.
Responsible for meeting individual quality performance standards and annual targets for program performance, such as monthly productivity and annual caseload requirements, as mutually agreed to by management team to maximize program value. Participates in Quality Improvement projects and data collection to determine effectiveness of Population Health Program.
May direct other staff in coordinating care.
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
Perform other job-related duties as assigned, within your scope of responsibilities.
Job duties are performed in a normal and clean office environment with normal noise levels.
Work is predominately done while standing or sitting.
The ability to comprehend, document, calculate, visualize, and analyze are required.
An Equal Opportunity Employer
All BCBSLA EMPLOYEES please apply through Workday Careers.
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Additional Information
Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.