Job Description :
This job is the primary clinician managing members wide range in health status/severity and clinical needs in either a case management or condition (disease) management program. The incumbent will be responsible for assessing health management needs of the assigned members and utilizing data/analytics present in FEP Direct Care Coordination Portal (HEDIS, pharmacy, appropriate site of service, high cost alerts, and member wellness profile to identify the member’s health-related conditions or serious medical issues.) The incumbent will be supported by an internal multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. The incumbent is responsible for interacting with external vendors (Nurse line, Rare Disease CM vendor), other Blue plans, and group – Blue Cross Blue Shield Association (BCBSA) Federal Employee Program Director’s applications and on occasions, the FEP DO Clinical Account Manager in care coordination.
- Maintain oversight over of Federal Employee members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support.
- Create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. for assigned case load.
- Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved.
- Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards under Highmark and the BCBSA guidelines.
- Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization.
- Function as a primary educator for members who have specific health conditions for which the organization has formal disease management programs. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making to optimize their clinical outcomes. Identify opportunities for plan and member savings through utilization of network providers, alternative clinical strategies or benefit options.
- Other duties as assigned.
- Bachelor’s Degree in Nursing
5 – 7 years Clinical Services or
5 – 7 yearsCase Management
5 – 7 years Disease/Condition Management or
5 – 7 years Health Insurance Industry
LICENSES or CERTIFICATIONS
- Registerd Nurse
- Certification in Case Management (CCM) – or ability to obtain a CCM within 2 years of hire.
- Oral & Written Communication Skills
- Influence and Persuasion
- Analytical and Logical Reasoning/Thinking
- Time Management
Languages (other than English)
0% – 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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