Case Manager

Pay Range $73,600.00 - $110,400.00 Please email View email address on click.appcast.io if you are a candidate seeking a reasonable accommodation for the application and/or interview process. At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join Others Who Value a Workplace For All. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer. Why This Job Matters Deploy corporate strategy for supporting members in obtaining best-fit care within immediate health care system and other supporting services while promoting access to evidenced based care. Educate, empower, and coordinate services for members to improve members’ well-being and moderate claims trends. Facilitate communication between identified care team members including but not limited to members and or their appointed representatives, providers, community-based organizations, and the health plan to ensure members receive the full benefit of integrated care. What You Will Do Manage members through evidence-based care, promote access to healthcare system, and assess needs to identify appropriate interventions. Member management includes, but is not limited to, the conduction of health assessments (telephonic and face-to-face) to identify high-risk or emerging risk members for education and intervention and the evaluation and modification of action plans by working with members and collaborating with providers. Evaluate member services to ensure appropriate levels and coordination of care, including pre-authorization, concurrent review, quality-of-care screening, and discharge planning. Ensure member and provider satisfaction by demonstrating knowledge of member plan benefits and community resources. Identify opportunities to moderate claims costs for the employer group and individual members. Promote and monitor the use of wraparound service programs for optimal member experience while managing chronic and acute care needs. Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans for improving members’ total health. Provide continuity and consistency of care by building positive relationships between members, families, providers, care coordinators, and the health plan. Engage in team operations including supervision, team huddles, staff meetings, case rounds, metric management, training opportunities, department initiatives, and projects. Work collaboratively to develop and implement solutions, identify barriers, and exemplify corporate values through accountability, collaboration, integrity, and respect. Perform other duties as assigned What You’ll Need To Succeed Unrestricted Rhode Island Nursing License Unrestricted Massachusetts Nursing License Three years’ experience in a medical/clinical environment or managed health plan Must obtain Certified Case Manager (CCM) certification within three years of employment The Extras Bachelor’s degree in nursing Certified Case Manager (CCM) Reside in Rhode Island or other Nurse Licensure Compact state (NLC) Bilingual Spanish, Portuguese Experience working in a managed care/health maintenance organization Experience implementing and upholding Quality, CMS, NCQA requirements Knowledge of utilization management and/or coordination of care Knowledge of population health and chronic condition management principles, aligning with corporate initiatives such as specialty within high-risk maternity and rising risk conditions such as diabetes, hypertension, COPD, etc. Understanding of health care delivery system access points and services Demonstration of successful (member) engagement via application of Motivational Interviewing techniques and health coaching Ability to navigate the healthcare delivery system Understanding of evidence-based care programs and approaches Strategic and critical thinking skills Strong analytical skills Strong business acumen Strong presentation negotiation, problem-solving, and decision-making skills Strong written and verbal communication skills Experience in health coaching and motivational interview techniques Ability to work effectively with a wide variety of people in individual and group settings Strong organizing skills, with the ability to prioritize and respond to shifting deadlines Strong time management skills Location and Role BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role: In-office: onsite 5 days per week Hybrid: onsite 2-4 days per week Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer. The law requires an employer to post notices describing the Federal laws. Please visit to view the "Know Your Rights" poster. #J-18808-Ljbffr