At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, gender identity or expression.
Working in a team environment, assist members in navigating the health care system, ensuring the members have access to evidenced based care. Educate, empower, and coordinate services for members, as well as perform utilization review, with goals of improving the members’ well being and moderating their claims trends. Interact with members, providers, external vendors, and any other party to ensure the members are receiving the full benefit of integrated care.
REPRESENTATIVE JOB DUTIES
KNOWLEDGE, SKILLS & ABILITIES REQUIRED:
- Manage members through the healthcare delivery system and assess their needs in order to identify appropriate interventions. Conduct telephonic health assessments to identify members at risk who would benefit from education and intervention. Work with members, their caregivers, providers, and outside vendors to develop, coordinate and implement action plans aimed at improving the members’ total health.
- Identify opportunities to moderate claims costs for the employer group and/or at the individual member level.
- Periodically evaluate action plans by working with members, and collaborating with providers. Modify action plans as necessary.
- Monitor and evaluate patient services to ensure appropriate level of continuity of care. Apply all aspects of the medical review function, including pre-authorization, concurrent review, screening cases for quality of care issues, and discharge planning. Document rationale for medical decision made.
- Promote member and provider satisfaction by demonstrating working knowledge of member benefits, including but not limited to health, disability, Employee Assistance or other plans/benefits available to the member by the employer. Provide continuity and consistency of care by building positive relationships between the member and family, physicians, provider, care coordinator, and health care plan.
- Review data and reports to identify members that would benefit from our services and to identify opportunities for outreach. Being innovative and working collaboratively with others, develop a plan and process to take action on these opportunities.
- Identify barriers to performing job duties as well as opportunities for improvements. Work collaboratively with the team and others necessary to develop and implement solutions.
- Work with providers, Medical Policy, etc. to coordinate the medical review process.
- Interact with members, providers, external vendors, and others demonstrating excellent customer service by providing them with valuable information and resolving any questions or problems that may arise, in a timely manner.
Knowledge of :
- Utilization management and/or coordination of care
- Population health and chronic condition management principles
- Health care delivery system access points and services available
- Knowledge of members individual benefit plan offerings
- Privacy Rules
- All aspects of the medical review function, including pre-authorization, concurrent review and discharge planning.
- Correct application of health care management guidelines.
Non-Technical Skills and Behaviors:
- Ability to proficiently navigate the Health Management and Integration systems detail oriented and a good problem solver.
- Excellent verbal, written and interpersonal communication skills, working with members to engage them in our interventions.
- Intermediate keyboard and software skills.
- Organizational skills.
- Detail oriented and a good problem solver.
- Follows the “Rules of the Road”.
- Delivers high quality service to customers.
- Applies expertise to get results.
- Seeks out different points of view to come up with the best solution.
- Finds “root cause” of problem to identify an effective solution.
- Gets quality deliverables quickly out the door.
- Changes work activities based on business needs and deadlines.
- Finds needed information in a timely manner.
- Monitors and communicates progress toward meeting goals.
- Highly developed interpersonal skills in order to interact effectively with internal and external customers.
- Persuasive skills required to negotiate, develop, influence, motivate, and move others through the stages of behavior change.
- Critical thinking and problem solving skills
- Ability to proficiently navigate the Health Management and Integration systems
- Work independently as well as in a team environment.
- Exercise sound judgment.
- Ability to take regulated processes and adapt them to an innovative environment.
- Take initiative in finding solutions to difficult and/or sensitive problems.
- Ability to identify opportunities and develop solutions for improving quality.
- Perform other duties as assigned.
Minimum Education and Experience:
Preferred Education, Additional Qualifications and Experience:
- Rhode Island Registered Nursing License (unrestricted).
- Three to Five years experience in a medical/clinical environment including but not limited to: acute inpatient, rehabilitation, sub acute, skilled facility, home care, or managed health plan experience.
- Associate’s Degree in Nursing
- Certified Case Management (CCM) certification, CPUR, or other job related nationally recognized certification (or sitting for the exam when eligible).
- One or more years experience in working in a managed care/health maintenance organization.
- Quality improvement/management experience.
- Demonstrated experience navigating through the complex medical system.
- Demonstrated experience facilitating the members’ healthcare needs through coordination with the members’ other benefit partners.
Blue Cross Blue Shield of Rhode Island - 13 months ago