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Primary Nurse Case Administrator

BlueCross BlueShield Health Care Services Type Full time Posted 8/19/2014
Salary - n/a - Starts - n/a -
TX - Texas (All) - Houston Referral - n/a -    

When you join Blue Cross and Blue Shield of Texas, you are teaming up with one of the best and most recognized health insurance organizations in the world. We are very proud that we continue to lead the industry in Customer Service and Member loyalty. Exceptional and customized service has always made us unique. Join us at our Houston Full Service Unit for the following position:

Primary Nurse Case Administrator
Job Req ID: FIW-1001223

This position is responsible for performing all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM) and is a single source of contact for members, health care personnel and all other entities involved in managing care. The Primary Nurse Coordinator performs concurrent review, discharge planning and care coordination; identifies alternate treatment programs; consults with physicians, providers, members, and other resources to evaluate options and services required to meet an individuals' health needs; promotes quality and cost effective outcomes; and serves as liaison to physicians and members. Other functions also include episodic case management, determining member assignment of treatment, and pre-admission/post-discharge counseling for an acute condition. Establish relationship with the member through the immediate post discharge follow-up period or until all short term care needs are met. Provide education/local resource information and encourage member (self) education. Functioning in a clinical care advisory role, the Primary Nurse Coordinator assesses members for wellness education and disease management, introduces members to our website tools, educates members regarding wellness and specific conditions, and facilitates the coordination of care for identified members.

*Registered Nurse (RN) with current, valid, unrestricted license in state of operations
*2 years clinical practice experience of direct clinical care to the customer
*1 year experience in Condition Management or Case Management in a health insurance/managed care setting, or health care experience
*PC proficiency to include Word, Excel, Lotus Notes and database experience
*Clear and concise verbal and written communication skills
*Knowledge of UM/CM/DM activities and standardized criteria set
*Familiarity of ancillary services including HHC, SNF, Hospice, etc
*Verbal and written communication skills; analytical skills; sound clinical judgment

*Experience in managing complex or catastrophic health cases
*Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
*Working toward or completion of CCM/CCP/CDE certification or Advanced degree
*Knowledge of Milliman Guidelines or similar clinical guidelines
*Knowledge of medical management policies and procedures

*Focus on the Customer
*Focus on Results
*Strategic Perspective

Please apply online at: www.bcbstx.com/careers, referencing Job Number FIW-1001223. Previous applicants must reapply.

We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Background investigations are required. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association