RN Specialist Complex Case Management - Transplant

The Impact You Will Have

This role will have primary responsibility for TransplantManagement!

Utilizing key principles of case management, the RN Specialist will research and analyze the member's health needs and healthcare cost drivers and will work closely with an interdisciplinary care team to ensure members have an effective plan of care that leads tooptimal, cost-effective outcomes. Leveraging clinicalexpertise, strong critical thinking skills and a keen business sense, the RN Specialist will work closely with the member and their family to avoid unnecessary hospitalizations and emergency departmentutilization,optimizesite of care whenever possible, and ensure evidence-based treatment is being applied. An experienced case manager with managed care experience will be successful in this role.

This position focuseson members going through the transplant experience. This clinician receives referrals andleveragesclinical and condition pathway knowledge for outreach stratification.

Your Responsibilities

• Receivesreferralformemberidentified withhigh cost, complex medical conditions and telephonically outreaches to the member,familyand providers to engage in complex case managementprogram.

• Conducts clinical assessments with members and providers utilizing motivational interviewing; gathers, analyzes, synthesizes and prioritizes member needs and opportunities based upon the clinical assessment and research and collaborates with the interdisciplinary care team to develop a comprehensive plan of care.

• Collaborates and communicates with the health care team; e.g. member, family, designated representative, health care provider on a plan of care that produces positive clinical results and promotes high-quality, cost effective outcomes.

• Identifiesrelevant BCBSMN and community resources andfacilitatesprogram and network referrals.

• Monitors, evaluates, and updates plan of care over time.

• Ensures member data is documented according to BCBSMN application protocol and regulatory standards.

• Maintains outstanding level of service at all points of customer contact.

• Understands the strategic and financial goals of the department, complex care management teams, and the enterprise

• Knowledgeable of health plan operations (e.g. networks, eligibility, benefits)

• Promotes innovative solutions to improve day to day functions and enhance the overall operation of the department.

• Collaborates with interdisciplinary care team to develop a comprehensive plan of care toidentifykey strategic interventions to addressmember'sneeds and health care cost drivers.

• Engage providerstelephonically in reviewingandunderstandingtreatment plans, including alignment with benefits and medical reimbursement policies tofacilitateoptimaltreatment plans, care coordination, and transition of care between settings.

• Identifiesand implementscost savingopportunities to ensureoptimaland cost-effective health outcomes.

Required Skills and Experience

• Registered nurse with current MN license and with no restrictions

• All relevant experience including work, education, transferable skills, and military experience will be considered.

• 5 years relevant clinical care experience

• CCM Certificate or ability to obtain within 3 years of starting in the position

• Excellent telephonic skills

• Keen business skills

• Excellent communication skills

• Excellent conceptual thinking skills

• Excellent relationship management skills

• Excellent organizational skills

• Computer application proficiency

• Strong resiliency and flexibility skills

• Excellent research, analytical, and creative problem-solving skills

• Flexibility to work varied hours

• High school diploma (or equivalency) and legal authorization to work in the U.S.

Preferred Skills and Experience

• 2+ years of managed care experience;e.g.case management/health coach,utilizationmanagementand/or auditing experience (may be included in the 5 years relevant clinical experience).

• 3 years relevant clinical care experience including transplant