Job Description - RN Case Manager Medicare
- Job Type : FULL_TIME
- Location : Remote / Work From Home
- Salary : $34 - $122 / HOUR
To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here.
Arkansas Blue Cross is only seeking applicants for remote positions from the following states:
Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Minnesota, Mississippi, Oklahoma, South Carolina, Tennessee, Texas, Virginia and Wisconsin.
Workforce Scheduling
Remote
Job Summary
The RN Case Manager assesses members with multiple and complex medical conditions who need post discharge care transition and/or short term complex care management, and conducts a person centered assessment, identifying barriers to care, developing a person centered care plan, conducting self-management education, ongoing monitoring of signs and symptoms and care coordination with consultations and grand round reviews. This position also refers to appropriate community services and health plan services and benefits to minimize barriers to care and the risk or unnecessary admission, readmission or emergency room utilization.
Requirements
Education & Experience:
• High School Diploma or Equivalent
• Current licensure as a Registered Nurse (RN) in applicable state or active license in a state allowing “multistate privilege to practice” or ability to obtain state licensure required
• Three (3) or more years of managed care clinical experience.
• Two (2) or more years of experience in case management and knowledge of chronic conditions (Diabetes, CHF, CAD and hypertension, COPD and Asthma, Renal Disease and mental health conditions including depression, bipolar disease) required.
• Previous STAR+PLUS Medicaid and or Medicare Managed Care experience preferred.
• Prior experience and knowledge of making referrals to community resource organizations preferred.
• Three (3) or more years’ experience in clinical case management of members with multiple and complex chronic conditions preferred.
• Certification as Case Manager or will agree to become certified within one year of hire preferred.
• Experience in telephonic counseling/coaching preferred.
• Bilingual English - Spanish preferred.
HOURS: 8am-5pm
Specialized Knowledge & Skills
• Excellent written and verbal skills in communicating with Members, Caregivers and providers required
• Excellent problem-solving skills and the ability to triage based on severity
• Excellent interpersonal skills and the ability to collaborate and work in a remote team environment
• Must be able to sit and work on a computer and use telephone for much of the workday required
• Proficiency in Microsoft Office Word, Excel and Windows-based systems required
• Ability to make sound judgments and decisions based on facts and guidelines, and the
• Ability to analyze problems, develop solutions, plan, organize, and control work for maximum efficiency
• Ability to train and educate others on the current processes
• Exercises a high level of integrity and handling confidential information
• Positive energy, drive and passion for end-to-end excellence, efficiency, and a track record for customer experience improvement
Skills
Responsibilities
Actively participates in interdisciplinary care teams; assures appropriate documentation in CM Systems are current prior to scheduled grand round meetings., Assists in the identification of member health education needs and monitors current clinical status by conducting assessments using approved motivational interview skills, assessment tools, identifying the need for physician or other intervention to prevent avoidable admission or readmission., Collaborates with team members such as Clinical pharmacist, Service coordinators, Medical Director, ancillary service providers and member's medical home provider and treating specialist as well as other case managers in order to eliminate or mitigate barriers., Collaborates with the member/family, physician, and health care providers/suppliers to discuss and prioritize the plan of care and prescribed treatment plan in accordance with evidenced based medicine and identified long and short term goals Accesses EMR and/or outreaches to obtain clinical records as necessary to establish the prescribed treatment plan, obtain results of tests and x-rays and other necessary clinical information for the purpose of treatment planning and operations. Develops, monitors, and evaluates the plan of care, extends, revises or closes the plan of care according to Interdisciplinary care team recommendations and communicates case management decisions., Collaborates with UM discharge managers to facilitate effective communication for members with multiple and complex medical conditions at higher risk of readmission assigned for post discharge transitions of care for the purposes of assisting with community resources, DME providers, referrals, housing and other related duties. Engages members in post discharge time, reviews discharge summary, completes assessments for assigned members in accordance with policy and refers member., Conducts telephonic assessments to identify barriers to care, equipment, medication management, self-care education and monitoring and establishing a medical home, community services and housing, establishing a medical home for routine preventive and chronic care management. Effectively manages a case load of 60 – 100 members and conducts outreach based on departmental policies and as often as necessary to effectively bring about stabilization of medical health and improved quality of care. Focuses on discharge members and mitigation of risk to readmission. Completes documentation in real time with approved documentation expectation and approved documentation templates., Consults with BH team members in cases where a member’s behavioral health or emotional issues are impacting their ability to set and/or achieve goals., Performs other related duties incidental to the work described herein, Prepares for member outreach by reviewing available medical history including known chronic conditions, whether or not the member is receiving routine chronic and preventive health care, if there are identified medication adherence issues and gaps in care based on predictive modeling reports, services that are in place and reviewing Service Coordination notes and HRA., Remote working with resourcefulness. Positions required 10% travel., Supports BH team in consultation when medical consult is needed., Understands and follows policies and procedures, completes documentation of interactions and interventions of assigned members in the CM systems as it applies using approved note templates, produces and submit reports in a timely manner and in accordance with workflows and policies, Utilizes approved evidence-based guidelines and general health and wellness strategies to achieve goals in the overall health of members., Works with members and treating physicians on opportunities to close gaps of care and to improve the member’s overall health status including attending and participating in rounds/care conferences. Empowers members with skills to provide enhanced interaction with their treating physicians such as preparing the member for the physician visit and writing down questions and concerns that they would like to discuss or clarify., Works with members to identify and set personalized health improvement plans and goals and support members in achieving those goals. Assesses the member’s readiness to change and implements actions to assist members in moving through stages of change to reach their goals.
Certifications
Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment Type
Regular
ADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting and routinely travels for work within walking distance of location of primary work assignment
#LI-Remote
