18 days old

Nurse Care Manager I

Blue Cross Blue Shield of Nebraska
Omaha, NE 68102
  • Job Code
Blue Cross and Blue Shield of Nebraska (BCBSNE) is more than just an insurance company; we exist to be there for people in the best and hardest moments of their lives.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it!

As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

As a Nurse Care Manager, you will work collaboratively with health care providers to ensure that members receive high quality, medically necessary care in a timely fashion in a setting that maximizes benefit coverage and health outcomes. You will also educate members to understand innovative benefit structures that promote transparency and affordability and empowers consumers to make informed decisions regarding their healthcare options, coverage, and financial risk. You will also assist members to navigate the complex health care settings and ensures they get the support they need throughout the episode of care to optimize health status.

What you'll do:

  • Follow the nursing process of assessment, planning, implementation, and evaluation of member-centric goals and interventions for members enrolled in the case management program.
  • Certification and authorization reviews to assess the medical necessity of inpatient admissions, outpatient services, out-of-network services, and appropriateness of treatment setting by utilizing and accurately interpreting applicable medical policy, clinical criteria, standards of care, contract language, benefits, and member eligibility. Facilitate appropriate and timely transitions of care utilizing member's contract language and clinical criteria. Identify members at risk for post-discharge complications or potentially preventable readmissions and follow-up with members after return home to ensure member is able to obtain medically necessary care, understands discharge instructions and plan of care, understands warning signs of complications and knows what actions to take to address changing health status.
  • Responsible to collaborate and consult with healthcare providers, members, and internal team of nurses, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.
  • Screen and triage members for levels and types of nurse advocacy and medical management programs, including but not limited to: discharge follow-up for potentially preventable readmissions, onsite visit program, care coordination, light touch care management, member outreach, palliative and hospice care management, and complex case management.
  • Act as a resource within the department and to other departments regarding medical management issues and activities.
  • Educate members about their benefits and coverage, and guide members to appropriate programs, community resources, and in-network providers.
  • Facilitates accreditation by knowing, understanding, and adhering to accrediting and regulatory requirements and standards.

To be considered for this position you must have:
  • Associates Degree in Nursing or Certified Practical Nurse and three (3) years clinical practice experience in a health care setting. An equivalent combination of education and experience may be substituted to meet this requirement.
  • The Nurse Care Manager must hold a valid and current Registered Nurse or License Practical Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates
  • The ability to meet or exceed the attendance and timeliness requirements of their departments.
  • The ability to work well in a team environment, and be capable of building and maintaining positive relationships with other staff, departments, and customers.

The strongest candidates for this position will also possess:
  • Bachelors Degree in Healthcare field
  • Certification in Case Management or Managed Care
  • Clinical experience in multiple levels of care
  • Three (3) years in discharge planning, utilization management, case management, or disease management
  • Knowledge of accreditation standards and regulatory requirements
  • Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans

Posted: 2020-10-05 Expires: 2020-11-03
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Nurse Care Manager I

Blue Cross Blue Shield of Nebraska
Omaha, NE 68102

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