Transplant Clinical Nurse, Case and Disease Management - Applicants must reside
Company: Blue Cross and Blue Shield of Kansas City
Location: Kansas City
Posted on: April 17, 2024
Job Description:
Guided by our core values and commitment to your success, we
provide health, financial and lifestyle benefits to ensure a
best-in-class employee experience. Some of our offerings
include:
- Highly competitive total rewards package, including
comprehensive medical, dental and vision benefits as well as a
401(k) plan that both the employee and employer contribute
- Annual incentive bonus plan based on company achievement of
goals
- Time away from work including paid holidays, paid time off and
volunteer time off
- Professional development courses, mentorship opportunities, and
tuition reimbursement program
- Paid parental leave and adoption leave with adoption financial
assistance
- Employee discount programJob Description Summary: Utilizes a
collaborative process of assessment, planning, facilitation and
advocacy for options and services to meet an individual's health
needs through communication and available resources to promote
optimal, cost-effective outcomes. Transplant only: Provides prior
authorization for, coordinates, and individually manages all member
transplants. Acts as an internal and external customer resource for
interpretation of transplant benefits and transplant-related claim
adjudication. Serves as a company expert on current and future
transplant types.Job Description
- Completes member assessments by collecting and analyzing
information across the seven domains of health and develops and
implements individualized care plans with appropriate interventions
in a culturally sensitive way. Uses standardized tools to complete
assessments in the areas of clinical, functional, financial,
support system, psychosocial and cognitive and environmental
realms.
- Monitors effectiveness of plan of care by gathering sufficient
information from relevant sources in order to intervene, as
appropriate, to improve health outcomes. Determines appropriate
intervals for monitoring plan of care. Utilizes internal, community
and other healthcare resources to maximize outcomes.
- Acts as liaison between member, employer, providers, support
system and BlueCross BlueShield of Kansas City. Works with multiple
members of the healthcare team to foster continuity and
coordination of care.
- Prioritizes interventions based on clinical need and readiness
to change. Educates and works with members at different educational
and health literacy levels. Utilizes clinical knowledge and
critical thinking skills to individualize evidence based
interventions. Assesses the member's need for education and tailors
teaching to the member's knowledge level and learning style.
- Meets individual quality performance standards and annual
targets for program performance as mutually agreed to by management
team to maximize program value. Ensures compliance with applicable
URAC and NCQA guidelines and state and federal regulations.
- Meets targets for program performance, such as monthly
productivity and annual caseload requirements as mutually agreed to
by management team to maximize program value.
- Schedules time effectively. Works with minimal supervision.
Handles multiple projects simultaneously. Prioritizes work
appropriately.Additional duties for Transplant only:
- Provides prior authorization of the transplant and manages
individual member cases. Reviews transplant evaluation and
authorizes in accord with medical policy. Opens case and follows
NCQA case management standards. Documents transplant authorization,
issues authorization letters, and follows in FACETS UM system in
accord with UM concurrent review guidelines. Consults with Medical
Director on cases outside medical policy, notifies providers and
members, if transplant benefits are denied, and explains appeal
rights.
- Educates members, providers, and other customers regarding
transplant benefits. Directly educates the transplant financial
coordinator of the transplant center, member and/or family members,
brokers, group and marketing reps, and other providers. Directly
educates internal customer service reps regarding individual
transplant benefits and the transplant network.
- Ensures proper payment of pre-transplant, transplant, and
post-transplant claims. Sets up transplant pre-pay review for each
individual claim. Reviews transplant billing packets and reconciles
with transplant centers if necessary. Continuously reviews FACETS
claim history to determine if claim has been paid or if
adjudication problems are occurring. Follows up with member and
transplant center during the global payment process to ensure
accurate payment. Responds to claims inquiries.
- Accurately reports potential high cost members and tracks costs
on members currently undergoing transplants.
- Serves as transplant information source for other departments
of the company (e.g., marketing department, senior management,
steering committee, contracting department, etc.).Minimum
Qualifications
- Associate degree in nursing or any combination of education and
experience providing the types and levels of knowledge, skills, and
abilities required by the job.
- 3 years full-time direct patient care clinical experience in
either of the following: transplant, oncology or
medical/surgical
- Ability to effectively present information and respond to
questions from groups of managers, clients, customers, and the
general public.
- Ability to define problems, collect data, establish facts, and
draw valid conclusions.
- Thorough knowledge of URAC and NCQA guidelines and state and
federal regulations.
- Valid and active Registered nurse (RN) in Missouri and
Kansas.
- Valid and active Registered nurse (RN) licensure in all 50
states and the District of Columbia initiated within 6 months and
completed within 15 months of hire date.
- Case Management Certification within 3 years of hire date or
within 3 years of transfer to Case Management
role/department.Preferred Qualifications
- Bachelor's degree in nursing with minimum of 5 years'
experience, including at least three years' of case management and
clinical transplant experience
- Intermediate level keyboarding skills
- Intermediate level knowledge of FACETS UM, CM and claims
applications.
- Experience in working with Health and Wellness and programs or
an understanding of wellness principles
- Thorough knowledge of NCQA guidelines and state and federal
regulations
- Intermediate level knowledge of Milliman guidelines .
- Case Management Certification within 3 years of hire date or
within 3 years of transfer to Case Management role/department.Blue
Cross and Blue Shield of Kansas City is an equal opportunity
employer. All qualified applicants will receive consideration for
employment without regard to, among other things, race, color,
religion, sex, sexual orientation, gender identity, national
origin, age, status as a protected veteran, or disability.
Keywords: Blue Cross and Blue Shield of Kansas City, Kansas City , Transplant Clinical Nurse, Case and Disease Management - Applicants must reside, Executive , Kansas City, Kansas
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