Pay Range:
$73,600.00 - $110,400.00
Please email [email protected] if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
At BCBSRI, our greatest resource is our people.
We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well.
We recognize that to do your best work, you have to be your best self.
It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.
Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued.
Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.
We’re dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.
Why this job matters:
Direct and coordinate the beneficiary’s care. Complete the HRA with the D-SNP member and/or the comprehensive assessment, coordinate care across the health care continuum, coordinating benefits, managing the members of the ICT, and developing and maintaining the ICP. Responsible for taking the problems/barriers from the HRA and incorporating into the ICP. Educate the beneficiary and/or caregiver on self-management strategies and skills. Collaborate with other team members, providers, community agencies and caregivers/ natural supports to facilitate the development of the ICP. Work closely with the health navigator to support self-management activities and the associated SMART goals. Facilitate communication among the beneficiary, providers, health plan, and others who participate in the beneficiary’s care. Provide consultation and support to the Behavioral Health Care Manager and other members of the ICT to support integrated care management delivery.
What you will do:
- Manage members through the healthcare delivery system; assess needs in order to identify appropriate interventions. Conduct telephonic or face to face health assessments to identify high risk or emerging risk members who would benefit from education and intervention. Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans aimed at improving the members’ total health.
- Identify opportunities to impact claims expense trends for the all lines of business/or at the individual member level. Evaluate action plans by working with members, and collaborating with providers. Modify action plans as necessary.
- Monitor and evaluate patient services to ensure appropriate coordination of care. Collaborate with the Utilization Review process including pre-authorization, concurrent review, screening cases for quality of care issues, and discharge planning.
- Promote member and provider satisfaction by demonstrating working knowledge of member benefits, including but not limited to health, disability, Employee Assistance or other plans/benefits available to the member
- Provide continuity and consistency of care by building positive relationships between the member and family, physicians, provider, care coordinator, and health care plan.
- Work collaboratively with the team and others necessary to develop and implement solutions. Identify barriers to performing job duties as well as opportunities for improvements. Exemplifying the corporate values in action through accountability, collaboration, integrity and respect in maintaining a high performance culture.
- Participate in department initiatives and projects. Perform other duties as assigned.
What you need to succeed:
- A combination of education and related work experience
- Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC), or unrestricted Registered Dietician License, independent license to practice behavioral health in RI such as Licensed Psychologist, Licensed Clinical Social Worker, or Licensed Mental Health Counselor.
- Three to five years’ experience in a medical/clinical environment or managed health plan
- Expertise working with D-SNP beneficiaries
- Must obtain Certified Case Manager (CCM) certification within three years of employment*
- *Applies to positions working with FEP product only
- Knowledge of utilization management and/or coordination of care
- Knowledge of population health and chronic condition management principles
- Understanding of health care delivery system access points and services
- Ability to navigate the healthcare delivery system
- Good business acumen
- Knowledge of business process improvement techniques and strategies
- Excellent verbal, written communications and technical skills
- Negotiation skills
- Presentation skills
- Decision-making skills
- Good problem solving skills
- Ability to interface with employees at all levels
- Ability to effectively navigate ambiguous situations with limited direction
- Excellent organizational skills and ability to successfully prioritize multiple tasks
- Ability to handle multiple priorities/projects
- Strong time management skills
The extras:
- Professional nursing certification
Experience working in a managed care/health maintenance organization
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Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:
- In-office : onsite 5 days per week
- Hybrid: onsite 2-4 days per week
- Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer.
The law requires an employer to post notices describing the Federal laws. Please visit www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.
