RN Case Manager (Complex Commercial)

RN Case Manager

The RN Case Manager is responsible for facilitating care for members and families of members who may have rising health risks or complex healthcare needs, to promote optimal health.

This position is self-directed and works independently and collaboratively to facilitate care based on the principles of care management. Facilitation is focused on assessing needs, identifying health care disparities, social determinants of health, and any barriers to care.

The RN Case Manager is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dietitians, pharmacists, clinicians, medical directors and more, who collaborate to facilitate care.

This role is eligible for the Resident, Mobile, and eWorker personas. This position can be fully remote with an expectation to work in our Hingham, MA office 1x/month.

Key Responsibilities:

• Engage members in appropriate plans of care, coordinate care and services as appropriate, communicate effectively and provide members with education and resources as needed. Promote member compliance with treatment plan, encourage shared decision-making, and set appropriate goals to promote optimal member outcomes.
• Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow and appropriately document comprehensive care management plans.
• Review medication list and educate members with complex pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.
• Successfully connect, engage, and maintain member engagement to support seamless care transitions and optimized health outcomes.
• Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
• Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.
• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.

Key Qualifications:

• Ability to identify and document member-driven, specific, measurable activities that address actionable behaviors and goals.
• Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
• Proficient with multiple IT systems.
• Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.

Education and Experience:

• 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).
• Utilization Management experience, preferred.
• Active licensure in Massachusetts is required.
• Licensure in additional states a plus.
• Note: Any restrictions against a license must be disclosed and reviewed.

Blue Cross Blue Shield of Massachusetts is an Equal Employment Employer - veterans/disability. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant.

Location: Hingham

Time Type: Full time

Weekly Hours: 37.5

Grade of Position

CRHourly Range: $42.78 - $52.29

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path.