Case Manager II - RN

CareFirst BlueCross BlueShield - Baltimore, MD

Resp & Qualifications

PURPOSE: In support of the CareFirst mission of providing affordable health insurance and accessible health care services, and utilizing key principles of case management, the Case Manager 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, the Case Manager 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.

PRINCIPAL ACCOUNTABILITIES: Under the general direction of the Supervisor or Manager of Care Management, the incumbent’s accountabilities include, but are not limited to, the following:

Case Management Process- Identification, Assessment, Developing and Implementing a Care Plan, Monitoring and Evaluating the Plan of Care.

  • Receives referral for member identified with 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.
  • Collaborates with interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member’s needs.
  • Identifies relevant CareFirst and community resources and facilitates program, network, and community referrals.
  • Monitors, evaluates, and updates plan of care over time. Ensures member data is documented according to CareFirst application protocol and regulatory standards.
  • Engages providers telephonically in reviewing and clarifying 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 customer service at all points.
  • Understands the strategic goals of the Medical Affairs Division, Care Management Department, and Clinical Management as well as the broader organization.
  • Responsible to provide innovative solutions to improve day to day functions and enhance the overall operation of the department.
Departmental Activities
Plays an active role in the day to day tasks associated with being a member of the case management department.

  • Completes mandatory training within the designated timeframe
  • Adheres to Departmental SOPs
  • Keeps current on clinical knowledge via self-directed learning
  • Actively Participates in Team meetings
  • Effectively escalates potential issues and/or system issues to Supervisor/Manager and provides an effective resolution
  • Collaborates with interdisciplinary teams
  • Other duties that support the mission, value and ethics of CareFirst and the goals of the Medical Affairs Division
Required Licensure/Experience/Education/Skills/Abilities:
  • Registered nurse with current Maryland, Virginia or DC license and with no restrictions.
  • 5 years of clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review or Disease Management.
  • Basic understanding of the strategic and financial goals of a health care system or payor organization. Basic understanding of health plan or health insurance operations (e.g. networks, eligibility, benefits).
  • 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.
  • Must have excellent analytical and problem-solving skills, excellent organizational, communication and coordination skills.
  • Must have effective presentation, negotiation and influencing skills to interface with all levels of management and physician practices.
  • Must be able to apply complex problem-solving abilities to achieve problem and process solutions.
  • Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
  • Knowledgeable of available community resources and programs.
  • 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 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.
  • Flexibility to work varied hours, and ability to travel by own means to a variety of locations to support business needs and to attend business meetings.
  • Bachelor’s degree, preferably a BSN
  • Working knowledge of managed care and health delivery systems
  • 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)
  • CCM/ACM or other RN Board Certified certification in case management.


Case Management

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:

Closing Date

Please apply before: 10/17/2019

Federal Disc/Physical Demand

Note: 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 or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship