Resp & Qualifications
In support of the CareFirst mission of providing affordable health insurance and accessible health care services, and utilizing key principles of case management, the High Cost Claimant Unit RN Specialist will research and analyze the member’s health needs and health care cost drivers and will work closely with an interdisciplinary care team to ensure members have an effective plan of care that leads to optimal, cost-effective outcomes. Leveraging clinical expertise, strong critical thinking skills and a keen understanding of the business operations of a health plan organization, the High Cost Claimant Unit RN Specialist will work closely with the member and their family to avoid unnecessary hospitalizations and emergency department utilization, optimize site of care whenever possible, and ensure evidence-based treatment is being applied. An experienced case manager with managed care and/or health plan experience and an interest in health economics will be most successful in this role.
Under the general direction of the Director of Care Management, the incumbent’s accountabilities include, but are not limited to, the following:
Receives referral for member identified with high cost, complex medical conditions and telephonically outreaches to the member, family and providers to engage in complex case management.
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.
Participates in a cross functional, multi-disciplinary team to identify and implement cost saving opportunities to ensure optimal and cost-effective health outcomes. Collaborates with interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member’s needs and mitigate health care cost drivers.
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.
Identifies relevant CareFirst and community resources and facilitates program and network referrals.
Monitors, evaluates, and updates plan of care over time. Ensures member data is documented according to CareFirst application protocol and regulatory standards.
Engage providers telephonically in reviewing and understanding treatment plans, including alignment with benefits and medical reimbursement policies to facilitate optimal treatment plans, care coordination, and transition of care between settings.
Maintains outstanding level of service at all points of customer contact.
Understands the strategic and financial goals of the department, Clinical Management team, and the broader organization.
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.
This a position where the incumbent must be capable of working with minimal oversight, showing keen attention to detail and making critical decisions to ensure members have an effective plan of care that leads to optimal, cost-effective outcomes.
- Registered nurse with current Maryland, Virginia or DC license and with no restrictions
- 5 years relevant clinical care experience
- CCM Certificate, or ability to obtain within 1 year of starting in the position
- Exhibits interest in and basic understanding of health economics. Embraces the corporate mission to ensure access to affordable care and applies clinical knowledge and skills with the business operations framework
- Excellent telephonic skills
- Keen business skills – understands business operations in a health plan or health care payor organization
- Excellent verbal and written communication skills
- Excellent conceptual thinking skills
- Excellent relationship management skills – ability to interface effectively with various types of levels of providers and CareFirst colleagues across multiple disciplines
- Excellent organizational skills (ability to prioritize, time management, workflow management)
- Computer application proficiency
- Strong resiliency and flexibility skills
- Excellent research, analytical, and creative problem-solving skills
- Flexibility to work varied hours
Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
2+ years of managed care experience; e.g. case management/health coach, utilization management and/or auditing experience (may be included in the 5 years relevant clinical experience)
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply:
Please apply before:
Federal Disc/Physical Demand
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle and feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship