**This position requires 24 months in role before being eligible to post for other internal positions**
This position is accountable for promoting collaboration with the member, physician/primary care manager, family/significant other and other members of the health care or case management team. This position is to analyze medical information provided by physicians and other health care practitioners to identify potential health care needs and to facilitate transition from the acute care setting. The Transition of Care Nurse 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 work location of this position will be based upon the selected candidates residence and may be located in either Johnson City (covering the Johnson City territory), or Memphis (Covering the Memphis Territory). Position may provide backup coverage in other territories within the state as needed.
Territory and schedule are subject to change as business needs.
Job Duties & Responsibilities
Assess clinical information to develop and implement treatment plans for transition to appropriate level of care
Coordinate the health care needs with the member, physician, family/significant other and health care providers (skilled nursing facilities, home health providers, rehabilitation facilities ) to accomplish the goal of transitioning member to the appropriate level of care.
Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provided.
Collaborate with member and health care team to set appropriate individual goals and time frames. Identify opportunities for intervention
Conducts any needed concurrent reviews at assigned hospitals to determine appropriate level of care and length of stay using established criteria
Provides on-site services to designated hospitals as assigned/necessary
Communicates with member, and/or family /significant other, and designated health care providers to assess, plan and implement care plans to transition the member to the appropriate level of care
Review request for health care services, according to guidelines, to ensure quality and cost effective care
Assess resource utilization and cost management; diagnosis, past and present treatment and prognosis.
Interacts with the other departments to ensure smooth transfer of member information across the continuum of care
Seeks advice of the Medical Director when medical judgment is required
Seeks assistance of appropriate individuals when network issues arise
Maintain requirements of documentation and caseload as reflected in audits to meet compliance with quality standards.
Conduct an evaluation of case, after closure. Collaborate with patient, family/significant other, physician and health care team regarding follow-up to evaluate status for health care needs.
Registered Nurse with an active Tennessee license or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
A Bachelors (or higher) degree in a health-related field preferred
Minimum of 5 years of health care experience, with at least three years of clinical experience required
Prefer 3 years of utilization review or case management experience
Certification as a Case Manager a plus
FACETS and Care Advance experience preferred
Must be PC literate with extensive knowledge of Windows and Microsoft Office. Must be able to pass Windows navigation test
Must possess excellent oral and written communication skills, with problem-solving abilities
Exceptional interpersonal skills required
Ability to multi-task
Excellent time management skills
Ability to meet and maintain established turn around time standards
Demonstrates a high level of clinical knowledge and ability to evaluate medical information to evaluate medical/behavioral needs
Job responsibilities require use and disclosure of a member's protected health information
BlueCross BlueShield of Tennessee - 21 months ago
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BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....