CareFirst BlueCross BlueShield
Onsite Clinical Navigator (Hybrid)
CareFirst BlueCross BlueShield, Baltimore, Maryland, United States, 21276
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Onsite Clinical Navigator (Hybrid)
role at
CareFirst BlueCross BlueShield
The Onsite Clinical Navigator (RN) embedded at a partnering hospital will conduct concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Onsite Clinical Navigator will leverage proficiency in established MCG and administrative/regulatory considerations to determine medical necessity, appropriate level(s) of care and case management to engage members/enrollees, their families and other support systems in discharge planning.
Essential Functions
Work onsite at assigned hospital facility utilizing clinical expertise and critical thinking skills to analyze available clinical information, EMRs, benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services, and engage onsite with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.
Collaborate with CareFirst medical directors, participate in internal case rounds/discussions to determine appropriate course of action and level of care, and make referrals to other care management programs and vendors as appropriate for chronic, long term care coordination.
Work collaboratively onsite with hospital teams to develop positive working relationships to decrease provider abrasion and improve member experience.
Qualifications
Education: Bachelor’s Degree in Nursing OR in lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 5 years clinically related experience working in Care Management, Home Health, Discharge Coordination and/or Utilization Review.
Preferred Qualifications: Knowledge and experience with MCG, experience working with Commercial and FEP employer group membership and Medicare/Medicaid enrollees and benefits contracts, CCM certification, MCG certification.
Knowledge, Skills and Abilities (KSAs)
Strong interpersonal skills and the ability to engage in a member facing onsite in-person environment while at the same time building relationships and partnerships with hospital care team and alternative care deliver partners to meet member/enrollee needs.
Strong clinical documentation skills, proficiency in web-based technology and Microsoft Office applications.
Strong analytical and problem solving skills to judge appropriateness of member services and treatments on a case-by-case basis.
Knowledge of clinical standards of care, disease process, national evidence based clinical guidelines and hospital operations.
Knowledge of available community resources and programs, basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations.
Ability to adapt to change while positively encouraging and motivating team members.
Licenses and Certifications Registered Nurse (RN) – State Licensure and/or Compact State Licensure: RN – Registered Nurse in MD, VA or Washington, DC upon hire required.
Salary Range $72,216 – $143,429
Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where to Apply Please visit our website to apply:
www.carefirst.com/careers
#J-18808-Ljbffr
Onsite Clinical Navigator (Hybrid)
role at
CareFirst BlueCross BlueShield
The Onsite Clinical Navigator (RN) embedded at a partnering hospital will conduct concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Onsite Clinical Navigator will leverage proficiency in established MCG and administrative/regulatory considerations to determine medical necessity, appropriate level(s) of care and case management to engage members/enrollees, their families and other support systems in discharge planning.
Essential Functions
Work onsite at assigned hospital facility utilizing clinical expertise and critical thinking skills to analyze available clinical information, EMRs, benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services, and engage onsite with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.
Collaborate with CareFirst medical directors, participate in internal case rounds/discussions to determine appropriate course of action and level of care, and make referrals to other care management programs and vendors as appropriate for chronic, long term care coordination.
Work collaboratively onsite with hospital teams to develop positive working relationships to decrease provider abrasion and improve member experience.
Qualifications
Education: Bachelor’s Degree in Nursing OR in lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 5 years clinically related experience working in Care Management, Home Health, Discharge Coordination and/or Utilization Review.
Preferred Qualifications: Knowledge and experience with MCG, experience working with Commercial and FEP employer group membership and Medicare/Medicaid enrollees and benefits contracts, CCM certification, MCG certification.
Knowledge, Skills and Abilities (KSAs)
Strong interpersonal skills and the ability to engage in a member facing onsite in-person environment while at the same time building relationships and partnerships with hospital care team and alternative care deliver partners to meet member/enrollee needs.
Strong clinical documentation skills, proficiency in web-based technology and Microsoft Office applications.
Strong analytical and problem solving skills to judge appropriateness of member services and treatments on a case-by-case basis.
Knowledge of clinical standards of care, disease process, national evidence based clinical guidelines and hospital operations.
Knowledge of available community resources and programs, basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations.
Ability to adapt to change while positively encouraging and motivating team members.
Licenses and Certifications Registered Nurse (RN) – State Licensure and/or Compact State Licensure: RN – Registered Nurse in MD, VA or Washington, DC upon hire required.
Salary Range $72,216 – $143,429
Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where to Apply Please visit our website to apply:
www.carefirst.com/careers
#J-18808-Ljbffr