We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.
Residency in or relocation to Louisiana is preferred for all positions.
POSITION PURPOSE
This position focuses care for members that have Medicare and are also entitled to Medicaid. The Case Management Nurse position is responsible for conducting case management, care coordination and quality activities in accordance to CMS standards and Blue Cross Blue Shield’s policies and procedures. The Case Management Nurse telephonically assesses members by evaluating member needs and requirements in order to achieve and/or maintain optimal wellness state. The Case Management Nurse will evaluate enrollees for resource needs and guide members and their families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The Case Management Nurse will work in collaboration with the member, the member’s care providers and a multi-disciplinary team, employing a variety of strategies, approaches and techniques to manage a member’s physical, environmental and psycho-social health issues.
NATURE AND SCOPE
- This role does not manage people
- This job reports to: Departmental Leadership
- Necessary Contacts: The departmental leadership, and other divisions within BCBSLA.
QUALIFICATIONS
Education
- High School Diploma required
Work Experience
- 4 years of general clinic experience is required.
- 1 year of clinical experience in case management, acute hospital discharge planning or utilization review is preferred.
- Previous direct clinical care to patients in a behavioral health setting is preferred.
Skills and Abilities
- Exceptional interpersonal, verbal, and written communication skills.
- Ability to document clearly and concisely.
- Strong problem-solving skills.
- Ability to work with limited supervision and make decisions based on established policies and procedures.
- Accountability – meets established expectations and takes responsibility for achieving results; encourages others to do the same. Employs focus, attention to detail, reliability, and appropriate prioritization to drive outcomes. Sees opportunities to contribute and takes the initiative to create solutions.
- Builds trust – consistently models and inspires high levels of integrity in decisions, speech, and actions. Lives up to commitments, taking responsibility for the impact of one’s actions. Prioritizes principles and values over personal or professional gain.
- Customer Focus – connects meaningfully with customers to build emotional engagement and customer advocacy. Develops and applies deep customer knowledge and intimacy to develop and deliver products, services, and interactions that provide value beyond expectations.
- Executes for results – effectively leverages resources to create exceptional outcomes. Determines the best course of action when facing ambiguity. Anticipates and constructively resolves barriers and constraints. Embraces change, applies new knowledge and reconfigures quickly to capitalize on opportunities.
- Understands or becomes knowledgeable of quality monitoring and improvement activities.
Licenses and Certifications
- Health Services\LPN - Licensed Practical Nurse - State Licensure currently licensed to practice in Louisiana with graduation from an accredited vocational or technical school for Practical Nursing 180 days required.
- Current Compact License or have the ability to obtain a Compact License within 90 days of hire.
- Case Management certification is preferred.
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
- Adheres to Dual Plus Plan Model of Care program goals and objectives to meet the member’s individualized health care needs through adherence to program policies and procedures.
- Actively participates in all enrollment activities.
- Performs telephonic case management and care coordination activities, communicating with the multidisciplinary team.
- Reviews each case individually and evaluates for referral to Social Services, Behavioral Health, Disease Management, community resources and other resource needs.
- Collects pertinent clinical information (including claims data when available), documenting findings using the Acuity case management system.
- Evaluates and completes the Health Risk Assessment which includes physical, psychological, emotional and environmental assessments, for the purpose of providing appropriate, timely interventions to ensure provision of optimal care.
- Coordinates community care and services as deemed appropriate.
- Develops an individualized care plan for each member along with the member and/or family and through collaboration with the Interdisciplinary Care Team (ICT).
- Provides ongoing evaluation and management of the member’s progress, effectives of the care plan, as well as the efficacy and appropriateness of services provided.
- Consults and collaborates with relevant departments as needed regarding member cases related to appropriateness of care, evidenced based clinical guidelines, medications and other treatment plans, individualized care plans and resource needs required to meet/manage the member’s level of care.
- Active member of the Interdisciplinary Care Team and actively participates in the ICT meetings.
- Participates in quality improvement processes.
- Serves as a liaison and patient advocate when deemed applicable or as requested by the patient or patient’s legally appointed representative.
- Additional responsibilities as deemed appropriate by Case Management leadership.
Additional Accountabilities and Essential Functions
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
- Perform other job-related duties as assigned, within your scope of responsibilities.
- Job duties are performed in a normal and clean office environment with normal noise levels.
- Work is predominately done while standing or sitting.
- The ability to comprehend, document, calculate, visualize, and analyze are required.
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An Equal Opportunity Employer
All BCBSLA EMPLOYEES please apply through Workday Careers.
PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
Additional Information
Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.
JOB CATEGORY: Insurance
