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Role Description

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 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 health care 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

• A combination of education and related work experience.
• Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC).
• Three to five years’ experience in a medical/clinical environment or managed health plan.
• Expertise working with D-SNP beneficiaries.
• Must obtain Certified Case Manager (CCM) certification within three years of employment.

Requirements

• Professional nursing certification.
• Experience working in a managed care/health maintenance organization.
• Bilingual preferred.
• Knowledge of utilization management and/or coordination of care.
• Knowledge of population health and chronic condition management principles.
• Understanding of health care 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, written communications, 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.

Benefits

• Flexible work arrangements that include remote and hybrid opportunities.
• Paid time off.
• Tuition reimbursement and assistance with student-loan repayment.
• Health, dental, and vision insurance.
• Programs that support mental health and well-being.
• Competitive pay, bonuses, and investment plans.
• Additional paid time to volunteer in the community.

Company Description

At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Our culture is one of belonging, striving to be transparent and accountable, and equipping our associates with the knowledge and resources they need to be successful.