This position is accountable for promoting interdependent collaboration with the member, physician/primary care manager, family and other members of the health care or case management team. To accomplish this collaboration, the case manager will assess, implement, monitor, and evaluate available resources in an effort to promote quality, cost effective outcomes while meeting the individual’s health needs. The case manager identifies appropriate providers and facilities in an effort to improve or maintain the social, emotional, functional and physical health status of the client, as well as enhance the coping skills of the family or other caregiver. The case manager functions in accordance to the needs of the member throughout the healthcare continuum. Related activities to Case Management include care coordination, complex condition management, Population Health Management through wellness, disease and chronic care management, and promoting transitions of care services.
Job Duties & Responsibilities
Conduct a thorough and objective evaluation of the client’s current status including physical, psychosocial, environmental, financial, and health status expectation.
As a client advocate, seek authorization for case management from the recipient of services (or designee).
Assess resource utilization and cost management; the diagnosis, past and present treatment; prognosis, goals (short- and long-term).
Identify opportunities for intervention.
Conducts any needed concurrent reviews to determine appropriate level of care and length of stay using established criteria
Provides on-site services as necessary
Interacts with other departments as necessary to ensure smooth transfer of member information across the continuum of care
Seeks advice of the Medical Director when appropriate
Set goals and time frames for goals appropriate to individual in accordance to case type requirements.
Arrange, negotiate fees for, and monitor appropriate cases and services for the client.
Maintain communication and collaborate with patient, family, physicians and health team members, and payer representatives.
Compare the client’s disease course to established pathways to determine variances and then intervene as indicated.
Routinely assess client’s status and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments to care, providers and/or services to promote better outcomes.
Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provided when appropriate.
Report quantifiable impact, quality of care and/or quality of life improvements.
Participate in Inter-reviewer reliability to identify quality of care issues and criteria inconsistencies.
Maintain requirements of documentation according to case type and caseload as reflected in audits to meet compliance with quality standards.
Conduct case screenings using applicable tools to determine appropriate levels needed to meet member needs.
The case manager will perform the six essential activities of case management in the appropriate manner as reflected by the case type. Detail will be reflected accordingly by the member’s needs within the continuum of care (wellness to catastrophic)
Assessment – The case manager will collect information about a person’s situation and functioning to identify individual needs in order to identify members risk for high cost medical care and develop an appropriate case management plan that will address those needs.
Planning – The case manager will determine specific objectives, goals, and actions as identified through the assessment process. The plan should be action oriented and time specific when appropriate and reflected by the case type.
Implementation – The case manager will execute specific intervention that will lead to accomplishing the goals established in the case management plan when appropriate and reflected by the case type.
Coordination – The case manager will organize, integrate, and modify the resources necessary to accomplish the goals established in the case management plan when appropriate and reflected by the case type.
Monitoring – The case manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the case management plan when appropriate and reflected by the case type.
Evaluation – At appropriate and repeated intervals, the case manager will determine the plan’s effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the case management plan in its entirety or in any of its component parts when appropriate and reflected by the case type.
Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
Adherence to the Corporate Tuberculosis Testing Policy 025.HR.078 and Tuberculosis Procedure 025.HR.078.A (if applicable)
Minimum of 5 years health care experience with at least three (3) years of clinical experience,
Prefer two (2) years experience in Utilization Management, Case Management or Managed Care.
CCM preferred; required to take examination when eligible. Case Managers must obtain a recognized certification in Case Management within four years of hire as a case manager or they will no longer be able to perform case management functions
Excellent oral and written communication skills, with problem-solving abilities.
Basic PC computer skills required with emphasis on Microsoft Office applications preferred
Various immunizations and/or associated medical tests may be required for this position.
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....