CareFirst BlueCross BlueShield
Clinical Navigator (Remote)
CareFirst BlueCross BlueShield, Baltimore, Maryland, United States, 21276
Inpatient Management Post Acute Clinical Navigator (RN)
Responsible for timely transition from inpatient to home or other levels of care. Utilizes case management and utilization management skills, proficiency in MCG to determine medical necessity and appropriate level of care. Engages members, families, and support systems in discharge planning.
Functions as liaison with Post-Acute Care team including case managers, social workers, and discharge planners to ensure members receive appropriate care and address potential barriers to discharge. Remote work within greater Baltimore metropolitan area. Expected to attend CareFirst location periodically for meetings, training and other business-related activities. Bilingual – fluent in Spanish a big plus.
Essential Functions
Analyze clinical information, EMR, benefit contracts, mandates, medical policy, evidence-based research to authorize inpatient services at post-acute services.
Engage member, family, and providers to identify strategic interventions, discharge planning and coordination to address medical, behavioral and social determinants of health.
Collaborate with medical directors and participate in internal case rounds to determine appropriate course of action and level of care. Apply sound clinical knowledge throughout review process. Follow member benefit contracts for benefit determination.
Make appropriate referrals to other Care Management programs as needed for chronic, long term care coordination.
Qualifications
Bachelor’s Degree in Nursing or 4 additional years of relevant work experience.
RN – active state licensure (MD, VA, DC).
5 years clinically related experience in care management, home health, discharge coordination, or utilization review.
Preferred: Bilingual – fluent in Spanish, knowledge of Milliman Care Guidelines, experience with employer group membership and Medicare/Medicaid enrollees, CCM certification.
Knowledge, Skills and Abilities
Strong interpersonal skills and ability to engage members in person or telephonically.
Strong clinical documentation skills and typing speed.
Proficient in web-based technology and Microsoft Office (Word, Excel, PowerPoint).
Strong analytical and problem-solving skills to judge appropriateness of member services and treatments.
Knowledge of clinical standards of care and national evidence-based guidelines.
Knowledge of community resources and programs.
Basic understanding of strategic and financial goals of a health care system and payer organization.
Compensation Salary range: $69,768 – $138,567. Travel to CareFirst locations required.
Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. All qualified applicants are encouraged to apply. The company provides equal employment opportunities to all applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
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Functions as liaison with Post-Acute Care team including case managers, social workers, and discharge planners to ensure members receive appropriate care and address potential barriers to discharge. Remote work within greater Baltimore metropolitan area. Expected to attend CareFirst location periodically for meetings, training and other business-related activities. Bilingual – fluent in Spanish a big plus.
Essential Functions
Analyze clinical information, EMR, benefit contracts, mandates, medical policy, evidence-based research to authorize inpatient services at post-acute services.
Engage member, family, and providers to identify strategic interventions, discharge planning and coordination to address medical, behavioral and social determinants of health.
Collaborate with medical directors and participate in internal case rounds to determine appropriate course of action and level of care. Apply sound clinical knowledge throughout review process. Follow member benefit contracts for benefit determination.
Make appropriate referrals to other Care Management programs as needed for chronic, long term care coordination.
Qualifications
Bachelor’s Degree in Nursing or 4 additional years of relevant work experience.
RN – active state licensure (MD, VA, DC).
5 years clinically related experience in care management, home health, discharge coordination, or utilization review.
Preferred: Bilingual – fluent in Spanish, knowledge of Milliman Care Guidelines, experience with employer group membership and Medicare/Medicaid enrollees, CCM certification.
Knowledge, Skills and Abilities
Strong interpersonal skills and ability to engage members in person or telephonically.
Strong clinical documentation skills and typing speed.
Proficient in web-based technology and Microsoft Office (Word, Excel, PowerPoint).
Strong analytical and problem-solving skills to judge appropriateness of member services and treatments.
Knowledge of clinical standards of care and national evidence-based guidelines.
Knowledge of community resources and programs.
Basic understanding of strategic and financial goals of a health care system and payer organization.
Compensation Salary range: $69,768 – $138,567. Travel to CareFirst locations required.
Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. All qualified applicants are encouraged to apply. The company provides equal employment opportunities to all applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
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