Management

Full job description We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.
Residency in or relocation to Louisiana is preferred for all positions.
This position is 100% remote in Louisiana. POSITION PURPOSE Utilize a collaborative process to assess, plan, implement, monitor, and evaluate options and services required to meet the member's healthcare needs. Through communication, the case manager will identify available resources to promote quality, cost effective outcomes. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.
NATURE AND SCOPE This role does not manage people This role reports to this job: MANAGER, POPULATION HEALTH Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with:Benefits Administration, Medical Director, Underwriting, Group leaders, Delegated Vendors, Legal Department and other employees as needed, physicians/staff, hospital administrators/staff, providers, caregivers, subscribers, community resources QUALIFICATIONS Education Bachelor's in nursing, business administration, healthcare or a related field is required RN license can be used in lieu of Bachelor's degree LPN license to practice in Louisiana as well as two years of related experience can be used in lieu of a Bachelor's degree Four years of related experience can be used in lieu of a Bachelor's degree. Work Experience 2 years Direct patient care/clinical experience. required Skills and Abilities Ability to research and analyze contracts/cases and make appropriate quality and cost effective decisions. Strong communication skills, including the ability to effectively explain/present claims information and procedures to persons with varied levels of insurance/benefits understanding. Excellent organizational and analytical skills. Ability to make decisions, prioritize, find solutions, and work independently. Working knowledge of related software and office equipment. Licenses and Certifications Nursing RN - Registered Nurse - State Licensure And/Or Compact State Licensure RN licensed to practice in Louisianarequired Nursing RN - Registered Nurse - State Licensure And/Or Compact State Licensure RN license to practice in states other than Louisiana is. Must attain RN license to practice in states other than Louisiana within 12 months after date of hire. preferred Case Management Certification or attained within 48 months after date of hire. preferred ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS Assess member's status by collecting in-depth information in culturally competent and confidential manner, about the member's situation and functioning to identify individual needs in order to develop and implement a comprehensive case management plan that will address needs for moderated to high risk cases. Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators. The case manager will act as an advocate for the member/family, maintaining privacy, confidentiality and safety, building relationships with all relevant parties, supporting informed decision making and facilitating access to necessary and appropriate healthcare services across the continuum of care. Implement specific interventions and evaluate effectiveness that will lead to accomplishing the goals established in the plan. Experienced in behavioral interviewing techniques. Coordinate by collaborating with the member/family, providers, third party payors, employers and community resources in order to organize, integrate, and modify the resources necessary to accomplish the goals. Assist with return to work, vocational development, and life care planning. Responsible for meeting annual targets for program performance as mutually agreed to by management team to maximize program value. Participates in quality improvement projects and data collection to determine the effectiveness of the case management program. Participates on project workgroups. Familiar with guidelines and requirements for authorizations of services related to coordination of care for complex cases. Proficient in care management authorization processes, including usage of standard clinical guidelines such as milliman care guidelines, as part of management of complex case management cases. Conduct case conferences with member, provider, and facilities as appropriate. May provide guidance to less experienced nurses.The physical demands described here are representative of those that must be met by an employee to successfully perform the accountabilities (essential functions) of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions. Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required. Additional Accountabilities and Essential Functions The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
Perform other job-related duties as assigned, within your scope of responsibilities. Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required. #LI_MS1
An Equal Opportunity Employer All BCBSLA EMPLOYEES please apply through Workday Careers. PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
Additional Information Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact for assistance.
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.
JOB CATEGORY: Insurance