RN Specialist Complex Case Manager

The Impact You Will Make

Utilizing key principles of case management, the RN Specialist will research and analyze the member's health needs and health care cost drivers and will work closely with an interdisciplinary care team to ensure members have an effective plan of care that leads to optimal, cost-effective outcomes. Leveraging clinical expertise, strong critical thinking skills and a keen business sense, the RN Specialist will work closely with the member and their family to avoid unnecessary hospitalizations and emergency department utilization, optimize site of care whenever possible, and ensure evidence-based treatment is being applied. An experienced case manager with managed care experience will be successful in this role.

Your Responsibilities:

• Receives referral for member identified with high cost, complex medical conditions and telephonically outreaches to the member, family and providers to engage in complex case management program.

• Conducts clinical assessments with members and providers utilizing motivational interviewing; gathers, analyzes, synthesizes and prioritizes member needs and opportunities based upon the clinical assessment and research and collaborates with the interdisciplinary care team to develop a comprehensive plan of care.

• Collaborates and communicates with the health care team; e.g. member, family, designated representative, health care provider on a plan of care that produces positive clinical results and promotes high-quality, cost effective outcomes.

• Identifies relevant BCBSMN and community resources and facilitates program and network referrals.

• Monitors, evaluates, and updates plan of care over time.

• Ensures member data is documented according to BCBSMN application protocol and regulatory standards.

• Maintains outstanding level of service at all points of customer contact.

• Understands the strategic and financial goals of the department, complex care managementteams, and the enterprise

• Knowledgeable of health plan operations (e.g. networks, eligibility, benefits)

• Promotes innovative solutions to improve day to day functions and enhance the overall operation of the department.

• Collaborates with interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member's needs and health care cost drivers.

• Engage providers telephonically in reviewing and understanding treatment plans, including alignment with benefits and medical reimbursement policies to facilitate optimal treatment plans, care coordination, and transition of care between settings.

• Identifies and implements cost saving opportunities to ensure optimal and cost-effective health outcomes.

Clinical Care Navigator:

Description Summary: This position will provide timely education and assistance to some members who are seeking services that are not medically necessary or a covered benefit. Assistance may be before or after member receives the notification of denial. The Clinical Care Navigator will walk alongside the member, helping identify next steps in their healthcare journey and collaborate with appropriate department resources. This clinician will be a single point of contact for the member and their family/representatives until resolution with the intent of preventing the case from becoming escalated.

Maternity Specialist:

Description Summary: Providing case management services to pregnant or recent post-partum members.

Transplant Specialist:

Description Summary: Focusing on members going through the transplant experience.This clinician receives referrals and leverages clinical and condition pathway knowledge for outreach stratification.

In addition to RN Specialist the Transplant Specialist requirements include:

• 3 years relevant clinical care experience including transplant

• 1 year of managed care experience; e.g. case management/health coach, utilization management and/or auditing experience (may be included in the 4 years relevant clinical experience)

Preferred Requirements: Transplant certification (CPTC, CCTC, CCTN)

Oncology Specialist:

Description Summary: RN Case Manager focusing on supporting members living with cancer and undergoing cancer treatment.

In addition to the RN Specialist the Oncology Specialist requirements include:

• 3+ years of recent Oncology experience in a Hospital or Clinic, Direct Care experience or experience as an Oncology Telephonic Case Manager for an insurance company

• Recent Chemotherapy administration experience

Preferred Requirements: Oncology certification (OCN) and or Chemo Administration Certification

Diabetic Specialist:

Description Summary: RN Case Manager focusing on supporting members living with Diabetes. Ensures evidence based clinical guidelines are part of the members treatment plan.

In addition to the RN Specialist Requirements the Diabetic Specialist requirements include:

• 3+ years of recent experience as a Diabetic Educator in an acute care setting or Diabetic Nurse or Diabetic Case Manager.

• Diabetic Education Certification or ability to obtain within 1 year of starting in the position.

Required Skills and Experience:

• High school diploma (or equivalency) and legal authorization to work in the U.S.

• Registered nurse with current MN license and with no restrictions

• All relevant experience including work, education, transferable skills, and military experience will be considered.

• 5 years relevant clinical care experience

• CCM Certificate or ability to obtain within 3 years of starting in the position

• Excellent telephonic skills

• Keen business skills

• Excellent communication skills

• Excellent conceptual thinking skills

• Excellent relationship management skills

• Excellent organizational skills

• Computer application proficiency

• Strong resiliency and flexibility skills

• Excellent research, analytical, and creative problem-solving skills

• Flexibility to work varied hours

Preferred Skills and Experience:

• 2+ years of managed care experience; e.g. case management/health coach, utilization management and/or auditing experience (may be included in the 5 years relevant clinical experience)

• Skilled in providing comprehensive care for maternity, postpartum, and newborn patients, ensuring their physical and emotional well-being.

Compensation and Benefits:

Pay Range: $77,200.00 - $102,300.00 - $127,400.00 Annual

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

To discover more about what we have to offer, please review our benefits page.