RN Specialist Complex Case Management

You will utilize key principles of case management to research and analyze the member's health needs and health care cost drivers and will work closely with an interdisciplinary care team to ensure members have an effective plan of care that leads to optimal, cost-effective outcomes. You will leverage clinical expertise, strong critical thinking skills and a keen business sense to work closely with the member and their family to avoid unnecessary hospitalizations and emergency department utilization, optimize site of care whenever possible, and ensure evidence-based treatment is being applied. An expert case manager with managed care experience will be successful in this role.

• Receives referral for member identified with high cost, complex medical conditions and telephonically outreaches to the member, family and providers to engage in complex case management program.
• Conducts clinical assessments with members and providers utilizing motivational interviewing; gathers, analyzes, synthesizes and prioritizes member needs and opportunities based upon the clinical assessment and research and collaborates with the interdisciplinary care team to develop a comprehensive plan of care.
• Collaborates and communicates with the health care team; e.g. member, family, designated representative, health care provider on a plan of care that produces positive clinical results and promotes high-quality, cost effective outcomes.
• Identifies relevant BCBSMN and community resources and facilitates program and network referrals.
• Monitors, evaluates, and updates plan of care over time.
• Ensures member data is documented according to BCBSMN application protocol and regulatory standards.
• Maintains outstanding level of service at all points of customer contact.
• Understands the strategic and financial goals of the department, complex care managementteams, and the enterprise
• Knowledgeable of health plan operations (e.g. networks, eligibility, benefits)
• Promotes innovative solutions to improve day to day functions and enhance the overall operation of the department.
• Collaborates with interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member's needs and health care cost drivers.
• Engage providers telephonically in reviewing and understanding treatment plans, including alignment with benefits and medical reimbursement policies to facilitate optimal treatment plans, care coordination, and transition of care between settings.
• Identifies and implements cost saving opportunities to ensure optimal and cost-effective health outcomes.

• Registered nurse with current MN license and with no restrictions
• All relevant experience including work, education, transferable skills, and military experience will be considered.
• 5 years relevant clinical care experience
• CCM Certificate or ability to obtain within 3 years of starting in the position
• Excellent telephonic skills
• Keen business skills
• Excellent communication skills
• Excellent conceptual thinking skills
• Excellent relationship management skills
• Excellent organizational skills
• Computer application proficiency
• Strong resiliency and flexibility skills
• Excellent research, analytical, and creative problem-solving skills
• Flexibility to work varied hours

• 2+ years of managed care experience; e.g. case management/health coach, utilization management and/or auditing experience (may be included in the 5 years relevant clinical experience)
• Experience within Behavioral Health
• Familiarity with NCQA
• Cultural competency. Experience working across races and cultures.