Medicare Advantage Case Management Triage Nurse at Blue Cross Blue Shield Kansas in Topeka, Kansas

Job Description:

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.


"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



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Why Join Us?

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  Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
  
  


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  Family Comes First: Total rewards package that promotes the idea of family first for all employees.
  
  


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  Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.
  
  


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  Stability: 80 years of commitment, compassion and community
  
  


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  Flexibility: options to work onsite, hybrid or remote available
  
  


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  Balance: paid vacation and sick leave with paid maternity and paternity available immediately upon hire
  
  


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  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 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.
  
  


• 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.).
  
  

What you need



Knowledge/Skills/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, weekends or be on call 365 days per year.
  
  

Education and Experience

• Registered nurse with minimum three to five years clinical RN nursing experience.
  
  


• Must become CCM certified within two years of assuming the position.
  
  


• 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. Apply Now