Registered Nurse -Case Manager
BCBSAZ is currently hiring for the following RN position:
Case Manager- prior case mgmt. in a managed care co/utilization mgmt. experience CCM preferred
Responsible for promoting continuity of care through a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates care options and services available to members through their benefit plan that meet the individuals' health care needs while promoting quality, cost effective outcomes.
•Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan.
•Answer a diverse and high volume of health insurance related customer calls on a daily basis.
•Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc.
•Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests.
•Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director.
•Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
•Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
•Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements.
•Maintain complete and accurate records per department policy.
•Demonstrate ability to apply plan policies and procedures effectively.
•Participate in continuing education and current development in the field of medicine and managed care at least annually.
•The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
Active current unrestricted AZ Registered Nurse license
•2 year(s) of experience in full-time equivalent of direct clinical care to the consumer. Case Mgmt/Utilization Mgmt preferred
•Associate’s Degree in general field of study or Post High School Nursing Diploma