Job Description Dependent on clinical discipline, the D-SNP Behavioral Health Case Manager / Health Coach coordinates appropriate care, resources and/or services of D-SNP member populations. Provides guidance and promotes effective utilization and monitoring of health care resources to drive quality care for our members. Collaborates as needed with varied members of the healthcare team to achieve optimal clinical and/or resource outcomes. What You'll Do • Serve as a team member on a multidisciplinary D-SNP team, coordinating care, resources and/or services for members to achieve optimal clinical and resource outcomes. • Utilize applicable clinical skillset and perform comprehensive assessments to determine how to best collaborate with members, family, internal partners and external services/providers on plans for treatment, appropriate intervention and/or discharge planning. • Develop a member-centric plan tailored to members’ needs, health status, educational status and level of support needs; identify barriers to meeting goals or plan of care • Utilize community resources and funding sources as needed in the development of the plan of care. • Perform ongoing monitoring and management of member which may include scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity. • Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care, etc). • Educate members and encourage pro-active intervention to limit expense and encourage positive outcomes • Effectively document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome. • May outreach directly to members identified as high risk, high cost, or high utilization cases. • May review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible. • May evaluate medical necessity and appropriateness of services as defined by department. • As needed, develop relevant policies/procedures, education or training for use both internally and externally. What You'll Bring • RN, RD or LCSW with 3 years of clinical and/or case management experience required • For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience • Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties • For some roles, additional specialty certification (i.e. CCM, CDCES) may be required. If so, incumbents must obtain relevant certification within 2 years of employment Bonus Points - D-SNP experience What You’ll Get - The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community  - Work-life balance, flexibility, and the autonomy to do great work   - Medical, dental, and vision coverage along with numerous health and wellness programs   - Parental leave and support plus adoption and surrogacy assistance   - Career development programs and tuition reimbursement for continued education   - 401k match including an annual company contribution   - Learn more   Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. *Based on annual corporate goal achievement and individual performance. $73,698.00 - $117,917.00 Skills Care Plan Development, Care Planning, Clinical Outcomes, Health Care, Healthcare Utilization Management, Medicaid, Nursing Fundamentals, Patient Advocacy, Patient Care, Patient Care Coordination, Patient Evaluations_____________________________________________________________________ JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: HR.Staffing@BCBSNC.com.

• Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries. • Assist with validation audits to evaluate medical record documentation, to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code. • Submit documentation to CMS for reimbursement and interpretation of medical documentation, to ensure capture of all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions that are applicable to Medicare Risk Adjustment reimbursement initiatives. • Attention to detail while reviewing patient’s clinical record. • Ensure regulatory compliance, and overall quality and efficiency by utilizing strong working knowledge of coding standards and EPIC.

• Provide a broad range of fully integrated audit services for our global clients. • High-quality deliverables covering complex sections with a reasonable number of workpaper comments. • Facilitate fieldwork and coordinate deliverables from multiple team members. • Demonstrates depth of knowledge of methodology, relevant standards, and systems. • Collaborate with Manager to guide associates and monitor productivity and workplan schedule. • Proactively addresses client concerns and escalates issues as they arise. • Interacts with clients and engagement teams to ensure efficient information flow.

Role Description Perform professional auditing work with responsibility for examining and analyzing financial functions, program and systems operations and results to determine compliance with tax, financial, or programmatic procedures and regulations. Work requires knowledge and application of the theories, principles, and practices of accountancy and auditing, as well as knowledge of the statutory requirements of specific programs and the related information technology standards. Perform complex, specialized auditing of financial, programmatic functions, and systems. - Independent examination and analysis of risks, internal controls, complex reports, records, financial statements, and systems for accuracy, completeness, and conformance to guidelines and statutes. - Justifies and defends audit findings for unprecedented and controversial cases. - Serves as a technical resource for unique or unprecedented issues. - Conducts presentation of audit findings and reports to various campus clients. - Creates and presents training presentations on various topics to various campus audiences. Work Schedule 8:00 am – 5:00 pm; Monday – Friday