CareFirst BlueCross BlueShield
Onsite Clinical Navigator (Hybrid)
CareFirst BlueCross BlueShield, Baltimore, Maryland, United States, 21276
Overview
Onsite Clinical Navigator (Hybrid) – CareFirst BlueCross BlueShield. The Inpatient Management Onsite Clinical Navigator (RN) embedded at a partnering hospital conducts concurrent review of inpatient level of care and manages the transition from inpatient care to home or other levels of care. The role leverages experience in care management and utilization management to determine medical necessity and appropriate levels of care, engaging members and their support systems in discharge planning. The position works onsite at the assigned hospital up to 5 days per week with occasional weekend work at management’s discretion. There may be limited telephonic functions and periodic visits to the CareFirst office for meetings or training. Primary residence should be in Montgomery or Prince George’s County. Bilingual – fluent in Spanish is a big plus.
Responsibilities / Essential Functions
Work onsite at the hospital facility to analyze clinical information, EMRs, benefit contracts, mandates, medical policy, evidence-based research, accreditation and regulatory requirements to determine appropriateness and authorization of inpatient services.
Engage members, families, and providers to identify interventions, discharge planning, and coordination to address medical, behavioral, and social determinants of health for a safe transition to the appropriate level of care or home.
Collaborate with CareFirst medical directors and participate in internal case rounds to determine the appropriate course of action and level of care; apply clinical judgment and follow member benefit contracts for benefit determination.
Make referrals to other care management programs and vendors as appropriate for chronic and long-term care coordination.
Work collaboratively with hospital teams to build strong relationships and improve member experience.
Qualifications
Education Level:
Bachelor’s Degree in Nursing or, in lieu of a Bachelor’s degree, an additional 4 years of relevant work experience in addition to required work experience.
Licenses/Certifications:
RN – registered nurse with state licensure and/or compact state licensure; RN licensed in MD, VA, or Washington, DC upon hire.
Experience:
5 years clinically related experience in Care Management, Home Health, Discharge Coordination and/or Utilization Review.
Preferred Qualifications:
Knowledge of MCG; experience with Commercial/FEP employer group membership and Medicare/Medicaid enrollees and benefits contracts; CCM and MCG certifications.
Knowledge, Skills And Abilities:
Strong interpersonal and member-facing communication, clinical documentation, proficiency with EMRs, Word, Excel, PowerPoint; analytical and problem-solving skills; knowledge of clinical standards and community resources; ability to meet deadlines and provide quality customer service.
Additional Skills:
Adaptability, onsite hospital assignment with travel up to 5 days/week, vaccination and training requirements as specified, and compliance with infection control and safety trainings.
Other Details
Salary Range:
$72,216 - $143,429
Department:
Inpatient DRG Telephonic
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
Note:
Onsite Hospital Assignments are subject to change based on evolving business needs. The incumbent is required to disclose any debarment, exclusion, or other event that makes them ineligible to perform work on Federal health care programs. Physical demands include mostly seated work with occasional walking or standing, writing and typing, and occasional lifting up to 25 pounds. Must be eligible to work in the U.S. without sponsorship.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other, Information Technology, and Management
Industries
IT Services and IT Consulting, Financial Services, and Hospitals and Health Care
Referrals increase your chances of interviewing at CareFirst BlueCross BlueShield by 2x
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Onsite Clinical Navigator (Hybrid) – CareFirst BlueCross BlueShield. The Inpatient Management Onsite Clinical Navigator (RN) embedded at a partnering hospital conducts concurrent review of inpatient level of care and manages the transition from inpatient care to home or other levels of care. The role leverages experience in care management and utilization management to determine medical necessity and appropriate levels of care, engaging members and their support systems in discharge planning. The position works onsite at the assigned hospital up to 5 days per week with occasional weekend work at management’s discretion. There may be limited telephonic functions and periodic visits to the CareFirst office for meetings or training. Primary residence should be in Montgomery or Prince George’s County. Bilingual – fluent in Spanish is a big plus.
Responsibilities / Essential Functions
Work onsite at the hospital facility to analyze clinical information, EMRs, benefit contracts, mandates, medical policy, evidence-based research, accreditation and regulatory requirements to determine appropriateness and authorization of inpatient services.
Engage members, families, and providers to identify interventions, discharge planning, and coordination to address medical, behavioral, and social determinants of health for a safe transition to the appropriate level of care or home.
Collaborate with CareFirst medical directors and participate in internal case rounds to determine the appropriate course of action and level of care; apply clinical judgment and follow member benefit contracts for benefit determination.
Make referrals to other care management programs and vendors as appropriate for chronic and long-term care coordination.
Work collaboratively with hospital teams to build strong relationships and improve member experience.
Qualifications
Education Level:
Bachelor’s Degree in Nursing or, in lieu of a Bachelor’s degree, an additional 4 years of relevant work experience in addition to required work experience.
Licenses/Certifications:
RN – registered nurse with state licensure and/or compact state licensure; RN licensed in MD, VA, or Washington, DC upon hire.
Experience:
5 years clinically related experience in Care Management, Home Health, Discharge Coordination and/or Utilization Review.
Preferred Qualifications:
Knowledge of MCG; experience with Commercial/FEP employer group membership and Medicare/Medicaid enrollees and benefits contracts; CCM and MCG certifications.
Knowledge, Skills And Abilities:
Strong interpersonal and member-facing communication, clinical documentation, proficiency with EMRs, Word, Excel, PowerPoint; analytical and problem-solving skills; knowledge of clinical standards and community resources; ability to meet deadlines and provide quality customer service.
Additional Skills:
Adaptability, onsite hospital assignment with travel up to 5 days/week, vaccination and training requirements as specified, and compliance with infection control and safety trainings.
Other Details
Salary Range:
$72,216 - $143,429
Department:
Inpatient DRG Telephonic
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
Note:
Onsite Hospital Assignments are subject to change based on evolving business needs. The incumbent is required to disclose any debarment, exclusion, or other event that makes them ineligible to perform work on Federal health care programs. Physical demands include mostly seated work with occasional walking or standing, writing and typing, and occasional lifting up to 25 pounds. Must be eligible to work in the U.S. without sponsorship.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other, Information Technology, and Management
Industries
IT Services and IT Consulting, Financial Services, and Hospitals and Health Care
Referrals increase your chances of interviewing at CareFirst BlueCross BlueShield by 2x
#J-18808-Ljbffr