With the support of the lead case management triage nurse coordinator, carries primary and independent responsibility for the day-to-day activities of researching, reviewing, processing, initial screening and triage of members identified in the resource utilization programs as well as those identified from any other source. Responsible for appropriate identification and referral of members for potential case management (CM) intervention. Responsible for testing discharge call outreach (DCO) system development as needed. Responsible for conducting all activities in compliance with State, URAC, HIPAA, DOL, CMS, and MTM goals and/or guidelines.
"This position must complete a required onsite training. Upon completion of the initial six-month training period, this position will be eligible for remote or hybrid (a minimum of 9 days per month onsite) work option, 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
Flexibility: options to work onsite, hybrid or remote available
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
Responsible for collaborating/coordinating with the case managers and supervisor/management to identify, clinically research and triage potential members for CM.
Responsible for coordinating CM identification activities with case managers and other area staff for optimal efficiency of processes.
Responsible for activities and collaboration with other areas of the company (e.g. health analytics, disease management) to identify and promote management of appropriate Blue Cross and Blue Shield of Kansas (BCBSKS) members and achievement of other corporate goals (e.g. HEDIS/Stars) which may involve participation of the CM area.
Perform initial clinical review on referred cases. This may include FEP plan to plan referrals not sent directly to a case manager, to include any needed claims system or care coordination portal review of member information/alerts as needed.
Responsible for triage of referred cases to other programs or resources as needed (e.g. pharmacy, disease management, rare disease management, other wellness programs, etc.)
Conducts review of medical information without direct supervision. Must determine through independent medical knowledge which cases require CM input or medical consultant expertise. All such determinations must be made under limited time constraints.
Assist in answering the general CM telephone lines for all lines of business and triaging the calls to the appropriate case manager, other area of the company, or handle as appropriate.
Maintain appropriate activity level and case documentation to meet URAC, CMS, group and/or corporate requirements.
Responsible for performing all job functions within the scope of the Kansas Nurse Practice Act.
Responsible for conducting resource utilization program activities (e.g. post discharge member contact, avoidable emergency department use, etc.).
Knowledge, Skills, and Abilities:
Ability to communicate effectively, verbally, in writing, and via telephone regarding confidential and sensitive issues while maintaining a positive professional image.
Ability to problem solve using analytical reasoning and research.
Ability to self-direct, self-motivate, make independent decisions, and prioritize/organize daily activities.
Awareness and understanding of current medical care practices.
Schedule could require alternative work hours, which may include evenings and weekends.
What you need
Registered nurse with minimum three to five years clinical RN experience.
Acute medical/surgical preferred.
Bachelor of Science in Nursing (BSN) preferred.
Experience with government programs is helpful.
Physical Requirements
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.
