Blue Cross Blue Shield of Michigan

Role Description Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments. - Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. - Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols. - Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards. - Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities. - Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels. - Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc. - Identify and document quality of care issues; resolve or route appropriate area for resolution. - Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care. - Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc. - As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services. - Other duties may be assigned based on designated department assignment. Qualifications - Bachelor's degree in nursing, allied health, business, or related field preferred. - Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc. - Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. - One (1) year health insurance plan experience or managed care environment preferred. - Registered Nurse with current unrestricted Michigan Registered Nurse license required. - Certification in Case Management may be preferred based upon designated department assignment. - Excellent written and verbal communication skills. - Excellent customer service and interpersonal skills. - Working knowledge of current industry Microsoft Office Suite PC applications. - Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management. - Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. - Knowledge of cost containment strategies, BCN/BCBSM policies and procedures, member benefits and community resources. - Knowledge of applicable accreditation standards, local, state and federal regulations. - Other related skills and/or abilities may be required to perform this job based upon designated department assignment. Requirements - Registered Nurse with current unrestricted Michigan Registered Nurse license, Licensed Physical Therapist or Licensed Occupational Therapist required. - Extensive experience in post-acute (Skilled Nursing, Inpatient Rehab or Long-Term Acute Care) facilities. Company Description

This opportunity is available for individuals that reside in the following areas with a compact license: - Colorado, Georgia, Indiana, Kentucky, Massachusetts, Minnesota, Mississippi, Ohio, Pennsylvania, Virginia, Washington, Louisiana, and Iowa. The Care Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs. They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the BCBSM online messaging platform. The Care Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the member’s health across the care continuum. They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals. - Lead the coordination of a regionally aligned, multidisciplinary team to provide holistic care to meet member needs telephonic and/or digitally. The multidisciplinary team is inclusive of Medical and Behavioral Health Social Workers, Registered Dietitians, Pharmacists, Clinical Support Staff and Medical Directors. - Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members’ health across the care continuum. - Assess the member's health, psychosocial needs, cultural preferences, and support systems. - Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care, and promotes improved overall health outcomes. - Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services). - Coordinate care delivery and support among member support systems, including providers, community-based agencies, and family. - Advocate for members and promote self-advocacy. - Deliver education to include health literacy, self-management skills, medication plans, and nutrition. - Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate as necessary. - Accurately document interactions that support management of the member. - Prepare the member and/or caregiver for discharge from a facility to home or for transfer to another healthcare facility to support continuity of care. - Educate the member and/or caregiver about post-transition care and needed follow-up, summarizing what happened during an episode of care. - Secure durable medical equipment and transportation services and communicate this to the member and/or caregiver and to key individuals at the receiving facility or home care agency. - Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals - Continue professional development by completing relevant continuing education and maintaining Certified Case Manager (CCM). QUALIFICATIONS - Nursing Diploma or Associates degree in nursing required. - Bachelor’s degree in nursing strongly preferred. - 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required. - 1 year of case management experience in a managed care setting strongly preferred. - Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred. - Current, active, and unrestricted Michigan Registered Nurse license required - Certification in Case Management (CCM) required or to be obtained within 18 months of hire - Certification in Chronic Care Professional (CCP) preferred - Ability to think critically, be decisive, and problem solve a variety of topics that can impact a member’s outcomes. - Empathetic, supportive and a good listener. - Proficient in motivational interviewing skills. - Demonstrated time management skills. - Organizational skills with the ability to manage multiple systems/tools, while simultaneously interacting with a member. - Must have intermediate computer knowledge, typing capability and proficiency in Microsoft programs (Excel, OneNote, Outlook, Teams, Word, etc.). - Must embrace teamwork but can also work independently. 8. Excellent interpersonal and communication skills both written and verbal.