Case Management Nurse

Case Management NurseThis 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 ScopeThis role does not manage peopleThis job reports to: Departmental LeadershipNecessary Contacts: The departmental leadership, and other divisions within BCBSLA.Qualifications EducationHigh School Diploma requiredWork Experience4 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 AbilitiesExceptional 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 CertificationsHealth 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.Accountabilities and Essential FunctionsAdheres 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 functionsPerform 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.