RN Case Manager

About the role

The Clinical Care Manger facilitates care for members and families with rising health risks or complex healthcare needs, promoting optimal health through care management.

Responsibilities

• Continually assess and evaluate member and family needs using strong communication skills, critical thinking, clinical knowledge, data, and tools.
• Promote member compliance with treatment plan, encourage shared decision-making, and set appropriate goals for optimal member outcomes.
• Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow, and document comprehensive care management plans.
• Review medication lists and educate members with complex pharmacy needs, counseling on side effects and mitigation strategies for specific treatment protocols.
• Engage, maintain, and support member engagement for seamless care transitions and optimized health outcomes.
• Collaborate with a team of professionals, including clinical utilization managers, account representatives, member service associates, dietitians, and physicians, to provide high-level care coordination.
• Interact with treatment providers, PCPs, physicians, therapists, and facilities to gather clinical information for the plan of care.
• Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.
• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.
• Identify cases for medical rounds and follow up with providers on recommendations for optimal outcomes for members.
• Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support a diverse member population.
• Perform other clinical duties as assigned.

Qualifications

• Ability to identify and document member-driven, specific, measurable activities addressing actionable behaviors and goals.
• Self-directed, independent, adaptable, flexible, and collaborative.
• Ability to assess, analyze, draw conclusions, and construct effective solutions.
• Excellent written and verbal communication skills.
• Proficient with multiple IT systems.
• Able to identify and set goals, follow processes, meet deadlines, and deliver expected outcomes with urgency.
• Ability to interpret, evaluate, and document complex medical information to identify relevant and actionable conditions, circumstances, and behaviors.
• Demonstrated awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
• Willingness to learn new business and clinical skills.

Education and Experience

• 3-5 years relevant experience in various clinical health care settings (inpatient, outpatient, or differing levels of care).
• Case Management experience preferred.
• Certifications such as Case Management (CCM), certified diabetic educator, and Wellcoach certification are a plus.
• Active licensure in Massachusetts is required, appropriate to position (RN, LMHC, LICSW, LCSW).
• Licenses in additional states are a plus.

Location and Time Type

Hingham
Full-time

Pay

$44.12 - $53.93 per hour

Benefits

• Paid time off
• Medical/dental/vision insurance
• 401(k)
• Well-being benefits

Why Blue Cross Blue Shield of MA?

We value diversity and inclusion, and we strive to create an inclusive and rewarding workplace where everyone can thrive and contribute. We are committed to supporting your professional growth and providing the necessary resources to enable your success.