RN Case Manager

Job Overview The Clinical Care Manager is responsible for facilitating care for members and families of members who may have rising health risks or complex healthcare needs, to promote optimal health. This position is self‑directed, works independently and collaboratively, and is guided by the principles of care management. Key Responsibilities Continuously assess and evaluate member and family needs using strong communication skills, critical thinking, clinical knowledge, data, and tools. Promote member compliance with treatment plans, encourage shared decision‑making, and set appropriate goals to improve outcomes. Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow, and document comprehensive care management plans. Review medication lists and educate members with complex pharmacy needs; counsel on side effects and mitigation strategies for specific protocols. Successfully connect, engage, and maintain member engagement to support seamless care transitions and optimized health outcomes. Collaborate with a team of professionals—including clinical utilization managers, account representatives, member service associates, dietitians, and physicians—to provide high‑level care coordination. Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information for the plan of care. Monitor clinical quality concerns, make referrals, identify and address quality‑of‑care issues. Understand member insurance products and benefits, regulatory and NCQA requirements. Identify cases for medical rounds, follow up with providers on recommendations to achieve optimal outcomes. Support a positive workplace environment and share clinical knowledge to serve our culturally and demographically diverse member population. Perform other clinical duties as assigned. Key Qualifications Ability to identify and document member‑driven, specific, measurable activities that address actionable behaviors and goals. Self‑directed, independent, adaptive, flexible, and collaborative team member. Strong analytical and problem‑solving skills. Excellent written and verbal communication abilities. Proficiency with multiple IT systems. Goal‑oriented with a sense of urgency and ability to meet deadlines. Ability to interpret, evaluate, and document complex medical information. Awareness, attitude, knowledge, and skills to work effectively with a diverse population. Willingness to learn new business and clinical skills. Education and Experience 3–5 years of relevant experience in various clinical health‑care settings (inpatient, outpatient, or differing levels of care). Case management experience preferred. Certifications such as CCM, certified diabetic educator, or Wellcoach certification are a plus. Active licensure in Massachusetts required (RN, LMHC, LICSW, LCSW); licensure in additional states a plus. For RNs, a BSN is preferred. Minimum Education Requirements High school degree or equivalent, unless higher education is required by the above qualifications. Location & Compensation Location: Hingham, MA Time Type: Full time Hourly Range: $44.12 – $53.93 Benefits We offer a comprehensive benefits package, including paid time off, medical/dental/vision insurance, 401(k), and well‑being benefits to eligible employees. The role is also eligible for variable pay. Equal Employment Opportunity Statement Blue Cross Blue Shield of Massachusetts is an Equal Employment Opportunity employer and is committed to providing inclusive work environments. All qualified applicants will receive consideration for placement without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or other protected characteristic. We will not discriminate against applicants who engage in protected practices or inquire about pay. #J-18808-Ljbffr Blue Cross and Blue Shield of Massachusetts Inc.