RN Case Manager-BCN

<p>With more than 8,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust. Interested in joining us?</p>

Southfield, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />Learn more about your options as an external candidate. <a href="https://bcbsm.taleo.net/careersection/2/jobsearch.ftl?lang=en" target="_blank" rel="noopener noreferrer">Click here</a> to view open positions.&nbsp; http://www.bcbsm.com

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Competitive Total Compensation Package

Overview: <strong>Responsible for utilizing the nursing process in the development of treatment plans, with established goals, implementation, monitoring and evaluation of an assigned patient case loads in order to provide quality care appropriate to clinical needs.</strong>
Responsibilities: <ul> <li>Review and analyze referrals from a variety of sources for acceptance into the program.</li> <li>Evaluate patient needs, identify and recommend cost-effective health care options.</li> <li>Assure member health needs are consistent with nursing standards and practices, provide recommendations.</li> <li>Develop and monitor action plans established between member, family and/or designee and physician.</li> <li>Develop preauthorization review plans for the review of RN clinical cases.</li> <li>Make arrangements for DME supplies, medications, community resources and facilities.</li> <li>Educate patient and family and/or designee to processes, care practices, medication(s) and benefits.</li> <li>Review prescription drug coverage requests, transplant services, acute organ rejection episodes and/or requests for coverage.</li> <li>Prepare documentation, communicate findings and submit recommendations to medical policy, group representatives, and members of the health care team. (i.e. provider,&nbsp;subscriber, family).</li> <li>Coordinate the member appeals process for DOL, PA250/blended cases.</li> <li>Ensure clinical outcomes are met preventing future re-implantation.</li> <li>Review patient status, educate patient on self-management and ensure appropriate levels of post care education are provided.</li> <li>Identify potential gaps in member discharge to be avoided through education, empowerment and/or motivational interviewing.</li> <li>Clinical review of claims to ensure that correct reimbursement occurs.&nbsp;</li> <li>Internal peer review for quality performance.</li> <li>May conduct patient home visits to guarantee that the setting is safe and medical services are delivered.</li> <li>Continues professional development by attending relevant educational programs at lease annually.</li> </ul>
Requirements: <p><strong>EDUCATION AND/OR EXPERIENCE</strong></p> <ul> <li>Nursing diploma or associates degree in nursing required.</li> <li>Bachelor&rsquo;s degree in nursing or related field preferred.</li> <li>Two (2) to four (4) years of related clinical experience required.</li> <li>One (1) to three (3) years internal experience preferred.</li> </ul> <p><strong>OTHER SKILLS AND ABILITIES:</strong>&nbsp;</p> <ul> <li>Must have basic computer knowledge, typing capability and proficiency in Microsoft Word and Outlook.</li> <li>Knowledge of CM/DM principles, Care Advance system, NASCO and P&amp;P.</li> <li>Knowledge of HIPAA, American Disability Act, Clinical ethics, COB rules and Medical Policy.</li> <li>Familiarity with, crises call interventions, evidence based guidelines and alternate care.</li> <li>Knowledge of educational assessments and learning strategies.</li> <li>Knowledge of medical surgical principals, discharge planning, chronic diseases and clinical programs.</li> <li>Knowledge of current trends in related fields.</li> <li>Knowledge of benefits.</li> <li>Effective written and verbal communication and feedback.</li> <li>Effective organizational skills, ability to prioritize and flexibility.</li> </ul> <p><strong>CERTIFICATES, LICENSES, REGISTRATIONS</strong></p> <ul> <li>Registered Nurse with current unrestricted Michigan Registered Nurse license required.</li> <li>Certification in Case Management (CCM) preferred.</li> <li>Certification in Chronic Care Professional (CCP) preferred.</li> <li>North American Transplant Coordinator Association certification preferred.</li> <li>Case management experience and/or managed care experience (utilization review, discharge planning, home care) preferred.</li> <li>At least two years of experience in an acute care setting.</li> </ul>