With the support of the lead Medicare Advantage nurse coordinator, carries primary and independent responsibility for the day-to-day operations of reviewing, processing, and communicating with members and providers involved in case management activities which may include determining appropriateness and cost effectiveness of care in light of quality-of-care objectives. This position serves as primary negotiator with medical providers/vendors regarding reimbursement and provider write off of services involved in specific managed care cases. Also carries primary responsibility for pre and post-case management claim payment. Provide backup support for precert activities. Responsible for performing all activities within State, URAC, HIPAA, DOL, CMS, and MTM goals or guidelines.
"Upon completion of the initial six-month training period, this position will be eligible for hybrid or remote work. Alternatively, employees may choose to work onsite or in a hybrid capacity (a minimum of 9 days per month onsite), in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment."
Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.
Why Join Us?
Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
Lead and Inspire: Guide and mentor your team to achieve their full potential and success.
FamilyComes First: Total rewards package that promotes the idea of family first for all employees.
Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.
Trust: Work for one of the most trusted companies in Kansas
Stability: 80 years of commitment, compassion and community
Inclusive Work Environment: We pride ourselves on fostering a diverse and inclusive workplace where everyone is valued and respected.
Compensation
$72,000 - $86,000 annually Exempt 15
Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.
What you'll do
Must be knowledgeable and responsible for ensuring case management activities are performed in compliance within the current applicable URAC standards and CMS regulations to include documenting appropriate activity monitoring as well as compiling and reporting audit results.
Obtains, records, and coordinates all case management inquiries and relays information to departments including medical director, Blue Cross and Blue Shield of Kansas Customer Service representatives, claims staff, sales, institutional and professional relations, behavioral health vendor, and legal counsel when necessary.
Assume a leadership role in determining the financial direction of patient care. This diverse activity requires the case manager to facilitate the development of a treatment plan that will meet the patient's needs. On a limited basis, appropriately negotiates reimbursement with providers that will be acceptable to all parties (patient, family, providers, and Blue Cross and Blue Shield of Kansas) at the most cost-effective prices that will meet the patient's short and long-range goals. The case manager must determine if the sum of the cost of services will result in high quality care that is equal to or better than the alternatives. All cases require care coordination with multiple providers to include transitions of care as the patient moves through the health care continuum. Monitors ongoing services and evaluates plan effectiveness to facilitate changes, if appropriate.
Responsible for performing all job functions within the scope of the Kansas Nurse Practice Act, CMS regulations, Case Management Society of America (CMSA) Standards of Practice, and the Commission for Case Manager Certification (CCMC).
Responsible for providing clinical support for precertification/case management for commercial business, and alternative care activity as needed.
Participate in telephone and/or onsite case management decision teams, which may involve interaction with one or all of the following: patient, referring physician, treating physician, facility staff and caregivers, financial officers and/or representatives.
Maintains appropriate caseload, follows case management process to include appropriate timely documentation and follow-up.
What you need
Knowledge, Skills and Abilities
Ability to communicate effectively, verbally, in writing and via telephone regarding sensitive and confidential issues and maintain a positive professional image.
Ability to assess, analyze, plan, and evaluate situations.
Ability to self-direct, make independent decisions, and prioritize daily activities.
Ability to handle sensitive situations in a positive, professional manner.
Must be comfortable discussing reimbursement/financial arrangements.
Schedule could require alternative work hours, which may include evenings, weekends, availability 365 days per year.
Education/Experience
Registered nurse with minimum three to five years clinical nursing experience, acute medical/surgical preferred, Bachelor of Science in Nursing (BSN) preferred.
Must become CCM certified within two years of assuming the position.
Experience with government programs is helpful.
CCM Certification preferred.
Physical Requirements
90-95% of daily activity requires use of computer and/or telephone.
Benefits & Perks
Base pay is only one component of your competitive Total Rewards package
Incentive pay program (EPIP)
Health/Vision/Dental insurance
6 weeks paid parental leave for new mothers and fathers
Fertility/Adoption assistance
2 weeks paid caregiver leave
5% 401(k) plan matching
Tuition reimbursement
Health & fitness benefits, discounts and resources
Our Commitment to Diversity, Equity, Inclusion, and Belonging
At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of diversity, equity, inclusion, and belonging (DEIB), where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law.
We believe that embracing diversity and authentically promoting inclusion, equity, and belonging among our team members is crucial to our collective success. By intentionally recruiting, developing, and retaining a diverse pool of talent, we cultivate an environment where everyone feels valued, heard, and empowered to contribute. Accommodations are available for applicants with disabilities upon request, ensuring an inclusive and accessible hiring process for all.
