BlueCross BlueShield of Tennessee Medical Case Manager in Chattanooga, Tennessee

Effective 11/1/16: Employees who are required to drive his or her personal vehicle or a rental vehicle on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements; as defined in the “Use of Non BCBST-Owned Vehicle” Policy; and maintaining an acceptable motor vehicle record (MVR).

*The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.

This position is accountable for promoting interdependent collaboration with the member, physician/primary care manager, family and other members of the health care or case management team. To accomplish this collaboration, the case manager will assess, implement, monitor, and evaluate available resources in an effort to promote quality, cost effective outcomes while meeting the individual’s health needs. The case manager identifies appropriate providers and facilities in an effort to improve or maintain the social, emotional, functional and physical health status of the client, as well as enhance the coping skills of the family or other caregiver.

Job Description:

Job Duties & Responsibilities

Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions. (Applies to position specific sections as well)

The case manager will perform the six essential activities of case management.

  • Assessment – The case manager will collect in-depth information about a person’s situation and functioning to identify individual needs in order to identify members at risk for high cost medical care and develop a comprehensive case management plan that will address those needs.
  • Planning – The case manager will determine specific objectives, goals, and actions as identified through the assessment process. The plan should be action oriented and time specific.
  • Implementation – The case manager will execute specific intervention that will lead to accomplishing the goals established in the case management plan.
  • Coordination – The case manager will organize, integrate, and modify the resources necessary to accomplish the goals established in the case management plan.
  • Monitoring – The case manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the case management plan.
  • Evaluation – At appropriate and repeated intervals, the case manager will determine the plan’s effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the case management plan in its entirety or in any of its component parts.

Case Management Functions

  • Conduct a thorough and objective evaluation of the client’s current status including physical, psychosocial, environmental, financial, and health status expectation.
  • As a client advocate, seek authorization for case management from the recipient of services (or designee).
  • Assess resource utilization and cost management; the diagnosis, past and present treatment; prognosis, goals (short- and long-term).
  • Identify opportunities for intervention.
  • Set goals and time frames for goals appropriate to individual.
  • Arrange, negotiate fees for, and monitor appropriate cases and services for the client.
  • Maintain communication and collaborate with patient, family, physicians and health team members, and payer representatives.
  • Compare the client’s disease course to established pathways to determine variances and then intervene as indicated.
  • Routinely assess client’s status and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
  • Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provider.
  • Report quantifiable impact, quality of care and/or quality of life improvements as measured against the case management goals.
  • Participate in Inter-reviewer Reliability to identify quality of care issues and criteria inconsistencies.
  • Maintain requirements of documentation and caseload as reflected in audits to meet compliance with quality standards.
  • Conduct case screenings using applicable tools to determine appropriate levels needed to meet member needs.

Job Qualifications

Education

  • Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
  • Musthave or be able to be licensed in multiple states if required

Experience

  • Minimum of five (5) years health care experience with at least three (3) years of clinical experience,
  • Prefer two (2) years experience in Utilization Management, Case Management or Managed Care.

Skills/Certifications

  • Certified Case Manager (CCM®) credential preferred; required to take examination when eligible. Case Managers must obtain a CCM certification within 2 years of hire as a case manager or they will no longer be able to perform case management functions
  • Excellent oral and written communication skills, with problem-solving abilities.
  • Basic PC computer skills required with emphasis on Microsoft Office applications preferred
  • Various immunizations and/or associated medical tests may be required for this position.

Job Specific Requirements:

Experience in Oncology Nursing is Strongly preferred.

Number of Openings Available:

1

Worker Type:

Employee

Worker Sub-Type:

Regular

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or membership in a historically under-represented group.

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products in any form in Tennessee and where state law permits. A tobacco-free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a tobacco/nicotine test. An individual whose test result is positive for tobacco/nicotine will be disqualified from employment and the job offer will be withdrawn. Individuals who fail the tobacco/nicotine screening will be permitted to reapply for employment after 6 months, iftobacco/nicotine-free.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.

About Us

As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health for over 65 years. More than that, we're your neighbors and friends – fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow.