Case Mgr - DSNP

About the role

Direct and coordinate the beneficiary's care. Complete the HRA with the D-SNP member and/or the comprehensive assessment, coordinate care across the health care continuum, coordinating benefits, managing the members of the ICT, and developing and maintaining the ICP. Responsible for taking the problems/barriers from the HRA and incorporating into the ICP. Educate the beneficiary and/or caregiver on self-management strategies and skills. Collaborate with other team members, providers, community agencies and caregivers/ natural supports to facilitate the development of the ICP. Work closely with the health navigator to support self-management activities and the associated SMART goals. Facilitate communication among the beneficiary, providers, health plan, and others who participate in the beneficiary’s care. Provide consultation and support to the Behavioral Health Care Manager and other members of the ICT to support integrated care management delivery.

Responsibilities

• Manage members through the healthcare delivery system; assess needs in order to identify appropriate interventions.
• Conduct telephonic or face to face health assessments to identify high risk or emerging risk members who would benefit from education and intervention.
• Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the members’ total health.
• Evaluate action plans by working with members, and collaborating with providers.
• Modify action plans as necessary.
• Monitor and evaluate patient services to ensure appropriate coordination of care.
• Collaborate with the Utilization Review process including pre-authorization, concurrent review, screening cases for quality of care issues, and discharge planning.
• 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.
• Build positive relationships between the member and family, physicians, provider, care coordinator, and health care plan.
• Work collaboratively with the team and others necessary to develop and implement solutions.
• Identify barriers to performing job duties as well as opportunities for improvements.

Requirements

• A combination of education and related work experience
• Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC)
• Three to five years’ experience in a medical/clinical environment or managed health plan
• Expertise working with D-SNP beneficiaries
• Must obtain Certified Case Manager (CCM) certification within three years of employment*
• Knowledge of utilization management and/or coordination of care
• Knowledge of population health and chronic condition management principles
• Understanding of health care delivery system access points and services
• Ability to navigate the healthcare delivery system
• Good business acumen
• Knowledge of business process improvement techniques and strategies
• Excellent verbal, written communications and technical skills
• Negotiation skills
• Presentation skills
• Decision-making skills
• Good problem solving skills
• Ability to interface with employees at all levels
• Excellent organizational skills and ability to successfully prioritize multiple tasks
• Strong time management skills

Qualifications

• Professional nursing certification
• Experience working in a managed care/health maintenance organization
• Bilingual preferred

Skills

• Knowledge of utilization management and/or coordination of care
• Knowledge of population health and chronic condition management principles
• Understanding of health care delivery system access points and services
• Ability to navigate the healthcare delivery system
• Good business acumen
• Knowledge of business process improvement techniques and strategies
• Excellent verbal, written communications and technical skills
• Negotiation skills
• Presentation skills
• Decision-making skills
• Good problem solving skills
• Ability to interface with employees at all levels
• Excellent organizational skills and ability to successfully prioritize multiple tasks
• Strong time management skills

Benefits

• Pay Range $73,600.00 - $110,400.00
• Flexible work arrangements that include remote and hybrid opportunities
• Paid time off
• Tuition reimbursement
• Assistance with student-loan repayment
• Health, dental, and vision insurance
• Programs that support mental health and well-being
• Competitive pay
• Bonuses and investment plans
• Growth and development opportunities

Schedule

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week

Location

Role BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role: