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BCBSMA is seeking a new RN Medex Case Manager to join our elite Case Management & Utilization Review team in Medicare Advantage!
The RN Medex Case Manager focuses on arranging and coordinating services that a member needs to get well and stay well. The RN Medex Case Manager will be providing both case management and utilization review services for Medicare Advantage. The RN Medex Case Manager also works to remove barriers that prevent the member from engaging in an appropriate plan of care. The RN Medex Case Manager demonstrates strengths working independently as well as collaboratively within a highly matrixed environment. The RN Medex Case Manager will be working with a team of other dedicated and compassionate nurses and providers to help meet department business objectives and measures. The RN Medex Case Manager will be using a member-centric, collaborative process involving assessment, planning, targeted intervention and advocacy, for our members. The RN Medex Case Manager will work with the member to identify options and services that meet their specific health needs through the health care continuum to promote optimal, cost-effective outcomes.
Assess and evaluate member or family support needs by using various data tools and resources
Assist members and their families in the administration of their health plan benefits, promote medication compliance, coordinate care with treatment providers, PCP's and other providers including VNA providers
Assist the member in shared decision-making and goal setting
Collaborate within a team of professionals (supervisors, managers, account representatives, member service associates, and physicians) to provide care coordination appropriate for members
Interpret and apply case management criteria, processes, policies, and applicable regulatory standards
Monitor for clinical quality concerns and refers appropriately
Provides telephone triage and crisis intervention when situation warrants, collaborating with utilization management peers when appropriate
Will need to understand regulatory requirements for designated programs: Medicare, FEP, Commercial, and Medex
Utilization Review Services - Associate will conduct pre-certification, concurrent, and retrospective reviews when indicated and as allowed, for applicable product lines and levels of care, with emphasis on utilization management, discharge planning, coordination of services, clinical outcomes, and quality of services
Evaluation of member's clinical status, benefit plan /product, and appropriateness for internal and external programs and sites of service in order to facilitate determination of cost-effective, medically necessary plan of care
Interaction with treatment providers, PCPs, physicians, therapists, and facilities, as needed to gather clinical information support the plan of care
Regular interactions with case managers, supervisors, managers, and physicians to discuss level of care questions, concerns, discharge needs, and barriers to achieving the most cost-effective, medically appropriate plan of care.
Presentation of cases at rounds, during on site consultant /account assessments and follow-up with physicians as necessary to obtain physician input and achieve optimal outcomes
Ability to adapt and be flexible to change as priorities within this environment change constantly
Willingness to learn new skills from both a business and clinical perspective
Strong teamwork and communication skills as well as ability to be self-directive
Ability to analyze information to construct effective solutions
Execution and results (ability to set goals, follow processes, meet deadlines, and deliver expected outcomes with appropriate sense of urgency)
Cultural competence (demonstration of awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population)
Clinical assessment (ability to interpret, evaluate, and clearly document complex medical information using a directive and focused approach in order to identify relevant and actionable conditions, circumstances, and behaviors)
Care planning (ability to identify and clearly document member-driven, specific, measurable activities that address actionable conditions, circumstances, and behaviors in order to improve health outcomes and cost-effectiveness of services)
Member collaboration and engagement (ability to secure and maintain the motivation, participation, and collaboration of all relevant parties in a purposeful plan to improve health outcomes and cost-effectiveness of service delivery)
EDUCATION & TRAINING:
3-5 years of recent direct patient care experience, (home care, hospital, or extended care facility)
Active and unrestricted MA RN License, required ; Licensure in additional states a plus!
Must be able to work out of the Quincy, MA office Monday to Friday
Knowledge of Medicare plans and/or guidelines is required
Utilization Review, Case Management, triage and/or telephonic care management experience, highly desired
Bachelor's degree preferred in nursing; Associate's degree in nursing will be taken into consideration
Certified Case Manager (CCM) is preferred, required for some roles
Expert in Microsoft Office Suite programs and other Information Technology systems: JIVA, InterQual, and/or MedHOK experience is a huge plus!
SCHEDULE OF HOURS:
Standard working hours are Monday through Friday anywhere from 8am-6pm (Typical shift is 8:30-4:30)
You may be required to work one evening a week, until 8pm to support our west coast membership
You may be required to work one Saturday a month to accommodate our member's needs
Bluecross And Blueshield Of Massachusetts