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Blue Cross Blue Shields of Wyoming

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FEP Case Manager-RN

Details
  • Location: TBD which location in WY
  • Job Type: 40 Hours Per Week
  • Pay Rate: Salary
  • Schedule: Monday through Friday, Daytime Only (between 8:00am to 5:00pm)
Type: Current Job Openings
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Requirements

Minimum Two (2) years prior experience in case management as an RN or five (5) years as an RN in a health-related field is required.  Must have current unrestricted Wyoming license as RN or higher.  Must have an associate’s degree in nursing. Bachelor’s or Master’s degree in nursing preferred.  Must have and maintain certification as Certified Case Manager (CCM).  Active and unrestricted Wyoming license must be maintained in order to perform clinical functions.

General Purpose

Evaluate appropriateness of health care services based upon medical knowledge and condition of patient.  Application of benefits available through the individual or group health policy as they related to the patient’s medical condition.  The research of new procedures for determination of coverage under our products.

Review cases of members with acute or chronic conditions and collaborate with service providers, the patient and family, and internal resources to establish the most effective treatment plan within the provisions of the policy.  This position screens, assesses and develops case recommendations, educates patients and family, coordinates with providers and monitors and documents cases on an ongoing basis.

Essential Duties & Responsibilities

  • Work towards quality initiatives
  • Identify and assess members with acute or chronic conditions for possible case management (CM) intervention
  • Develop, coordinate and monitor a plan of care for members with case management needs and educate both the member and health care team of services allowed within the benefit plan
  • Develop a case management plan of care by initiating contact with the member/designated representative and their health care provider team after obtaining case management program consent from the member
  • Assess initial and ongoing needs with the member/family, health care team and case manager by completing a thorough assessment of medical records and contact with providers and patient
  • Collaborate in identifying appropriate alternatives to the present care and provide assistance with identified needs by collaborating with the member and member’s health care team
  • Participate in discharge planning, network with appropriate outside agencies and make appropriate referrals to alternative resources as needed
  • Document case information and practice per the case management policy and procedures and in accordance with case management accreditation standards
  • Verify member benefit eligibility for alternative care for medical necessity and appropriateness and initiate the request for service
  • Throughout the case management process, collaborate with internal and external medical, utilization management and customer service teams as needed in the collaboration and coordination of the member’s care
  • Has access to and refer cases to the appropriate medical consultant (MD/DO) for case consultation or to evaluate appropriateness of medical care or peer review of medical necessity.
  • Work with Director of Pharmacy when appropriateness of prescription drugs is in question
  • Must be familiar with the URAC organization and all of the standards

Other Duties & Responsibilities

  • Must practice within scope of licensure and the Wyoming Nurse Practice Act
  • Works in conjunction with medical staff under the direction of the CMO. Receives clinical oversight from CMO in accordance with our policies and procedures.
  • Keep all subscriber Personal Health Information (PHI) confidential
  • Interact well with other departments
  • Follow and adhere to appropriate guidelines and laws applicable to duties (HIPAA, ERISA, URAC, etc.)
  • Other duties as assigned
Supervisory Duties

None

Job Qualifications

Knowledge, Skill & Ability
  • Sound general nursing background
  • Must display the ability and desire to work with supervision to remain completely informed with a broad general knowledge of related work
  • Computer literacy and the skill required to execute the function
  • Professional phone and communication skills required
  • Must have good organizational skills and the ability to multitask
  • This position requires a specialized knowledge of the benefit structure, corporate procedures and polices relative to claims processing, in depth knowledge of existing health insurance contract benefit structures and payment processes. Interpersonal relationships are of extreme importance and must be carried out with professionalism.
Education, Licensure, or Formal Training
  • Must have current unrestricted Wyoming license as RN or higher.
  • Must have an associate’s degree in nursing. Bachelor’s or Master’s degree in nursing preferred
  • Must have and maintain certification as Certified Case Manager (CCM)
  • Active and unrestricted Wyoming license must be maintained in order to perform clinical functions.
Experience

Minimum Two (2) years prior experience in case management as an RN or five (5) years as an RN in a health related field is required.

Equipment & Environment

Material & Equipment Directly Used
  • Computer
  • Electronic health care processing software
  • Microsoft Office
  • Various on-line software
  • Fax, copy and scanning machines
  • Telephone
Working Environment / Physical Activities
  • Works in an open office environment
  • Physical activities include, but are not limited to, keyboard and mouse manipulation, hand carrying items short distances to various other departments
  • This position needs to be able to deal with pressure and deadlines

Access to Protected Health Information (PHI)

Access to PHI is broad due to job function requirement of responding to customer and provider appeals relative to claims payments, eligibility, contract benefits and any other inquiry.

Notes & Other Information

Position summary shown may not include ALL of the necessary knowledge, skill, and ability requirements.

Note: Position summary shown may not include ALL of the necessary knowledge, skill, and ability requirements.

Blue Cross Blue Shield of Wyoming
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