Case Management Coordinator

Company: Blue Cross Blue Shield North Dakota ( Learn More )

General Information
US-ND-Fargo
N/A
4 Year Degree
Full-Time
At least 3 year(s)
Negligible
False
False
Job Description Primary Objective of Position



Responsible for performing the primary functions of assessment, analyzing, planning, facilitating, and evaluating members that have potentially long-term, high-dollar or catastrophic medical conditions throughout the continuum of care for coordination of care along with performing medical reviews to determine medical necessity according to the benefit plan.



 



Essential Functions



1)      Identify and assess Members with complex, acute or chronic conditions for possible case management intervention.  Develop, coordinate and monitor a plan of treatment for the Member who has complex or long-term case management needs.



 



2)      Review/Determine benefits for FEP Hospice, Inpatient Acute Rehab admissions, Alternate Care Services (SNF, SWB, TCU, HHC, HSP), inpatient transplants, and pediatric habilitative therapy (pt, ot, st) for medical necessity and appropriateness. 



 



3)      Provide education and support to members with specific medical conditions to promote self-care and improve outcomes.  



 



4)      Process Provider and Member appeals per company standards.



  



5)      Research and Resource



a)      Available as a resource for external entities such as healthcare providers, other Plans, Members.



b)      Available as a resource to internal entities to assist with projects and inquiries (i.e. Claims assistance from IMR/PMR, Psych Nurse Coordinators, BSA, Medical Policy, Medical Directors, committees, Marketing, etc.)



 



      6)      Educate health care providers, members, community, and internal staff on programs carried out within the Case 



               Management department.



 



      7)      Responsible for projects as assigned. Examples:



Medical Management Manual



Corporate projects



Audits



Training/Mentoring



Policies and Procedures



UM/Benefit Management Coordinator coverage



Reports


Job RequirementsKnowledge



•         Current Medical and Nursing practices and theories



•         Utilization Management theories and practices



•         Case Management theories and practices



•         Benefit Plan benefits



•         ICD9 & CPT4 coding



•         Medical Policies



•         BCBSND payment/fee schedules



•         BlueCard and FEP regulations  



•         Institutional and Professional Claims Processing



•         Statistical analysis



 



Abilities/Skills



•         Communication (interpersonal, verbal, written)



•         Organized & prioritize workload



•         Problem solving



•         Negotiation skills



•         Analytical skills



•         Respect confidentiality



•         Travel as requested



•         Be proficient in the English language



•         PC Applications



•         Software (e.g. WORD, Excel)



 



Education/Experience



•         Registered Nurse (RN) degree, current ND Nursing License, minimum 2 years direct clinical experience



•         Previous case management experience desired.



•         CCM Certification preferred



 



OTHER INFORMATION



      Job Posting Policy 6.05



New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.



EQUAL OPPORTUNITY EMPLOYMENT



Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.



For questions, please email [Click Here to Email Your Resumé]



This job posting will be closed 05/05/2017 at 8:00AM CST. No further applications will be considered.