Blue Cross and Blue Shield of Kansas City
Clinical Nurse, Case and Disease Management - High Cost Claims
Blue Cross and Blue Shield of Kansas City, Kansas City, Missouri, United States, 64101
Job Description Summary
Utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote optimal, cost-effective outcomes. Transplant only: Provides prior authorization for, coordinates, and individually manages all member transplants. Acts as an internal and external customer resource for interpretation of transplant benefits and transplant-related claim adjudication. Serves as a company expert on current and future transplant types. The candidate for this position must reside in the Kansas City metropolitan area.
Benefits Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:
Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
Annual incentive bonus plan based on company achievement of goals
Time away from work including paid holidays, paid time off and volunteer time off
Professional development courses, mentorship opportunities, and tuition reimbursement program
Paid parental leave and adoption leave with adoption financial assistance
Employee discount program
Responsibilities
Completes member assessments by collecting and analyzing information across the seven domains of health and develops and implements individualized care plans with appropriate interventions in a culturally sensitive way. Uses standardized tools to complete assessments in the areas of clinical, functional, financial, support system, psychosocial and cognitive and environmental realms.
Monitors effectiveness of plan of care by gathering information from relevant sources to intervene as appropriate and improve health outcomes. Determines appropriate intervals for monitoring and utilizes internal, community and other healthcare resources to maximize outcomes.
Acts as liaison between member, employer, providers, support system and BlueCross BlueShield of Kansas City. Works with multiple members of the healthcare team to foster continuity and coordination of care.
Prioritizes interventions based on clinical need and readiness to change. Educates and works with members at different educational and health literacy levels. Tailors teaching to the member’s knowledge level and learning style.
Meets individual quality performance standards and annual targets for program performance as mutually agreed by management. Ensures compliance with URAC and NCQA guidelines and state and federal regulations.
Meets targets for program performance, such as monthly productivity and annual caseload requirements as mutually agreed by management to maximize program value.
Schedules time effectively and works with minimal supervision. Handles multiple projects simultaneously and prioritizes work appropriately.
Transplant-Specific Responsibilities
Provides prior authorization of the transplant and manages individual member cases. Reviews transplant evaluation and authorizes in accord with medical policy. Opens case and follows NCQA case management standards. Documents transplant authorization, issues authorization letters, and follows in FACETS UM system in accord with UM concurrent review guidelines. Consults with Medical Director on cases outside medical policy, notifies providers and members if transplant benefits are denied, and explains appeal rights.
Educates members, providers, and other customers regarding transplant benefits. Directly educates the transplant financial coordinator of the transplant center, member and/or family members, brokers, group and marketing reps, and other providers. Directly educates internal customer service reps regarding individual transplant benefits and the transplant network.
Ensures proper payment of pre-transplant, transplant, and post-transplant claims. Sets up transplant pre-pay review for each claim. Reviews transplant billing packets and reconciles with transplant centers if necessary. Monitors FACETS claim history to ensure payment and address adjudication problems. Follows up with member and transplant center during the global payment process.
Accurately reports potential high-cost members and tracks costs on members currently undergoing transplants.
Serves as a transplant information source for other departments within the company (e.g., marketing, senior management, steering committee, contracting).
Minimum Qualifications
Associate degree in nursing
3 years full-time direct patient care clinical experience in either transplant, oncology or medical/surgical
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public
Ability to define problems, collect data, establish facts, and draw valid conclusions
Thorough knowledge of URAC and NCQA guidelines and state and federal regulations
Valid and active Registered nurse (RN) in Missouri and Kansas
Case Management Certification within 3 years of hire date or within 3 years of transfer to Case Management role/department
Preferred Qualifications
Bachelor’s degree in nursing with minimum of 5 years\' experience, including at least three years\' of case management and clinical transplant experience
Valid and active RN licensure in all 50 states and DC within 15 months of hire date
Intermediate level keyboarding skills
Intermediate level knowledge of FACETS UM, CM and claims applications
Experience in health and wellness programs or understanding of wellness principles
Thorough knowledge of NCQA guidelines and state and federal regulations
Intermediate level knowledge of Milliman guidelines
Equal Opportunity Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.
Additional Information
Seniority level: Mid-Senior level
Employment type: Full-time
Job function: Health Care Provider
Industries: Insurance
Referrals increase your chances of interviewing at Blue Cross and Blue Shield of Kansas City. Get notified about new Registered Nurse jobs in Kansas City, MO.
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Benefits Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:
Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
Annual incentive bonus plan based on company achievement of goals
Time away from work including paid holidays, paid time off and volunteer time off
Professional development courses, mentorship opportunities, and tuition reimbursement program
Paid parental leave and adoption leave with adoption financial assistance
Employee discount program
Responsibilities
Completes member assessments by collecting and analyzing information across the seven domains of health and develops and implements individualized care plans with appropriate interventions in a culturally sensitive way. Uses standardized tools to complete assessments in the areas of clinical, functional, financial, support system, psychosocial and cognitive and environmental realms.
Monitors effectiveness of plan of care by gathering information from relevant sources to intervene as appropriate and improve health outcomes. Determines appropriate intervals for monitoring and utilizes internal, community and other healthcare resources to maximize outcomes.
Acts as liaison between member, employer, providers, support system and BlueCross BlueShield of Kansas City. Works with multiple members of the healthcare team to foster continuity and coordination of care.
Prioritizes interventions based on clinical need and readiness to change. Educates and works with members at different educational and health literacy levels. Tailors teaching to the member’s knowledge level and learning style.
Meets individual quality performance standards and annual targets for program performance as mutually agreed by management. Ensures compliance with URAC and NCQA guidelines and state and federal regulations.
Meets targets for program performance, such as monthly productivity and annual caseload requirements as mutually agreed by management to maximize program value.
Schedules time effectively and works with minimal supervision. Handles multiple projects simultaneously and prioritizes work appropriately.
Transplant-Specific Responsibilities
Provides prior authorization of the transplant and manages individual member cases. Reviews transplant evaluation and authorizes in accord with medical policy. Opens case and follows NCQA case management standards. Documents transplant authorization, issues authorization letters, and follows in FACETS UM system in accord with UM concurrent review guidelines. Consults with Medical Director on cases outside medical policy, notifies providers and members if transplant benefits are denied, and explains appeal rights.
Educates members, providers, and other customers regarding transplant benefits. Directly educates the transplant financial coordinator of the transplant center, member and/or family members, brokers, group and marketing reps, and other providers. Directly educates internal customer service reps regarding individual transplant benefits and the transplant network.
Ensures proper payment of pre-transplant, transplant, and post-transplant claims. Sets up transplant pre-pay review for each claim. Reviews transplant billing packets and reconciles with transplant centers if necessary. Monitors FACETS claim history to ensure payment and address adjudication problems. Follows up with member and transplant center during the global payment process.
Accurately reports potential high-cost members and tracks costs on members currently undergoing transplants.
Serves as a transplant information source for other departments within the company (e.g., marketing, senior management, steering committee, contracting).
Minimum Qualifications
Associate degree in nursing
3 years full-time direct patient care clinical experience in either transplant, oncology or medical/surgical
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public
Ability to define problems, collect data, establish facts, and draw valid conclusions
Thorough knowledge of URAC and NCQA guidelines and state and federal regulations
Valid and active Registered nurse (RN) in Missouri and Kansas
Case Management Certification within 3 years of hire date or within 3 years of transfer to Case Management role/department
Preferred Qualifications
Bachelor’s degree in nursing with minimum of 5 years\' experience, including at least three years\' of case management and clinical transplant experience
Valid and active RN licensure in all 50 states and DC within 15 months of hire date
Intermediate level keyboarding skills
Intermediate level knowledge of FACETS UM, CM and claims applications
Experience in health and wellness programs or understanding of wellness principles
Thorough knowledge of NCQA guidelines and state and federal regulations
Intermediate level knowledge of Milliman guidelines
Equal Opportunity Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.
Additional Information
Seniority level: Mid-Senior level
Employment type: Full-time
Job function: Health Care Provider
Industries: Insurance
Referrals increase your chances of interviewing at Blue Cross and Blue Shield of Kansas City. Get notified about new Registered Nurse jobs in Kansas City, MO.
#J-18808-Ljbffr