Pay Range:$73,600.00 - $110,400.00
Please email if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
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: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
