This position is responsible for case management (excluding Behavioral Health) initiating a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs, utilizing plan benefits and community resources. The incumbent will utilize communications and available resources to promote quality and cost effective outcomes.
Nature & Scope
The incumbent's charge is to work with referrals from multiple sources to identify appropriate candidates for case management.
• Utilization Management (Pre-cert./Pre-notification)
• Trigger Diagnoses
• Chronic condition management
• Reports and analytics
• Medical Records
• Customer Service/Health Care Advisor
• Health Assessment
• Blue Touch Point
The incumbent will facilitate formation of health care teams to include patients, families/caregivers, physicians, and all other ancillary providers. Incumbent must have the ability to communicate at all levels, often in a highly charged, emotional environment. This incumbent should be a highly detailed professional who can work well with other health care personnel and interact well with patients and their families.
This position works closely with the Team Leaders, Supervisor, and Management for the implementation of medical management programs for all BANA business.
Minimum Job Requirements
- 1. Registered Nurse with current state license and in good standing with clinical practice experience.
- 2. CCM Certification required. If certification not obtained prior to employment, must sit for exam after 12 months of employment. If not passed on first attempt, must re-test and pass within 2 years of employment.
- 3. A bachelors (or higher) degree in a health related field preferred.
- 4. Experience in case management, home health, critical care, medical/surgical, social work, and discharge planning or concurrent review.
- 5. Keyboarding skills.
- 6. Average PC navigation skills.
- 7. Excellent interpersonal skills and above average communication skills.
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
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
PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1. Facilitate appropriate cost effective and cost containment measures.
2. Adhere to URAC Management Standards.
3. Practice case care management within the scope of licensure.
4. Cooperate and work effectively with all departmental staff to facilitate services to members and providers of care.
5. Remain current with medical and surgical procedures, products, services, and drugs by attending conferences, home studies, and in-services.
6. Monitor effective claims adjudication based on guidelines for contracted services.
7. Participate in quality improvement program.
8. Prompt case findings which are essential to assure timely transfer to lower levels of care.
9. Work closely with hospital discharge planners and home care providers to establish plan,
identify the appropriate setting, including necessary equipment is in place and operational,
and providers being available upon discharge.
10. Contact member and physician explaining case management services, ensuring that all
parties involved agree to voluntary case management services.
11. Monitor contracted and case by case negotiations with providers for quality of care
issues, cost effectiveness, accessibility, and levels of services provided utilizing JCACHO
providers when possible.
12. Must be able to maintain a minimum patient caseload of at any given time and
13. Work referrals daily.
14. Maintain continuous, effective communication with internal and external vendors.
Arkansas Blue Cross and Blue Shield - 5 months ago