- Serves as a customer advocate by identifying underlying customer needs and guiding them to appropriate programs and resources.
- Utilizes BCBSMN customer service systems and tools to deliver Care Advocacy to designated accounts.
- Identifies opportunities for connecting members to group related benefits; e.g. Nurse Line, Employee Assistance Program, or other specialists with in BCBS Health Management Division.
- Educates members on the use of their health delivery system and tools.
- Participates as a resource to internal and external customers.
- Responsible for answering customer questions pertaining to product information, benefits, claims resolution and eligibility in a call center environment.
- Conducts comprehensive clinical assessments; gathers, analyzes, synthesizes and prioritizes member needs and opportunities.
- Develops a plan of care to address identified gaps in care and improve members health.
- Collaborates and communicates with member, family, or designated representative on a plan of care that produces positive clinical results and promotes high-quality effective outcomes.
- Identifies relevant BCBSMN and community resources and facilitates warm program and network referrals.
- Monitors and evaluates plan of care over time.
- Ensures member data is documented according to BCBSMN application protocol and regulatory standards.
- Collaborates and coordinates with team members to facilitate day to day functions and enhance the overall operation of the department.
- Guides member through the Prior Authorization and Appeals process.
- 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.
- Registered nurse with current MN license and with no restrictions.
- Seeking fluent bilingual Spanish speaker
- 5+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
- CCM Certification or ability to obtain within 3 years of starting in the position.
- Excellent customer service skills.
- Excellent communication skills.
- Excellent conceptual thinking skills.
- Excellent relationship management skills and the ability to quickly gain customer trust and confidence.
- Excellent organizational skills.
- Ability to thrive in ambiguity.
- Computer application proficiency.
- Flexibility to work varied hours.
- 1+ years of managed care experience; e.g. case management/health coach, utilization management and/or auditing experience.
- Outstanding customer service and telephonic skills.
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Care Advocacy Case Manager RN - St Paul, United States - Blue Cross Blue Shield of Minnesota
Description
About Blue CrossBlue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We're committed to reinventing health care to improve health for our members and the community. We hope you'll join us.
How Is This Role Important to Our Work?
This position exists to support member needs across the continuum of care by leveraging member partnership, pre-service clinical utilization review, case and disease management processes, skill sets and tools. Care Advocacy Health Coach is responsible for answering customer questions pertaining to product information, benefits, claims resolution and eligibility in a call center environment. This position is a critical component of BCBSMN Medical Management team as the primary clinician providing condition and case management services to members.
A Day in the Life:
Required Skills and Experiences:
Nice to Have:
Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.
Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to
All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.
Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
