Responsible for utilizing the nursing process in the development
of treatment plans, with established goals, implementation of those plans, and
monitoring and evaluation of an assigned case load of patients in order to
provide them with the quality care appropriate to meet their clinical needs.
Reviews and analyzes referrals
from a variety of sources for acceptance into the program. Troubleshoots problems and
submits recommendations. May be required
to interface with other areas, both internally and externally, to resolve
problems. Consults and collaborates with Medical Consultants, Medical
Directors, Professional Team and Health Care Providers to develop treatment
plans and goals on an as needed basis. May develop educational and treatment
plans by working with the patient and/or designee and family in agreement with
physicians that will assure safe and cost effective quality of care. Reviews
status of patient in regards to established goals as appropriate. May contact
health care providers for assessment of the clinical status of the patient. May
analyze clinical reports utilizing approved standards and document results
attained. May conduct patient home visits to guarantee that the setting is safe
and that medically necessary services are being delivered and that treatment
goals are realistic and attainable on an as needed basis. Coordinates discharge
planning initiatives on an as needed basis. May perform clinical review of
claims to ensure that correct reimbursement for covered and/or approved services
occurs. May perform internal peer review for quality performance. May assist
with the design, development, modification, testing, implementation and
maintenance of assigned systems. Assumes leadership responsibilities when
necessary. Other duties may be assigned.
Degree in Nursing or RN Diploma required.
Bachelor's Degree preferred.
(2) to (4) years of clinical experience, preferably in Case Management or Home
Health Care with a Medical/Surgical background.
Demonstrated clinical knowledge and experience
relative to patient care and health care delivery processes.
knowledge of Case Management principles and procedures based on nationally
recognized standards of Case Management.
of BCBSM benefits preferred.
Registered Nurse with current
Michigan Registered Nurse license required.
Certification in Case
Certification in Chronic Care Professional
North American Transplant
Coordinator Association certification may be needed.
Clinical Programs & Medical Informatics
Blue Cross Blue Shield of Michigan - 16 months ago