Assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet an individual's health needs through the use of plan benefits and community resources to facilitate appropriate cost effectiveness and cost containment measures are met.
Other duties as assigned.
Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations and makes decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
Provides specialized education and knowledge on disease specific conditions as needed and assigned.
Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery, enterprise procedures, policies and contracts.
Serves as a liaison facilitating a collaborate process which includes patients, families/caregivers, physicians, hospital discharger planners, home care providers and other ancillary providers to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
Works proactively with referrals from multiple sources to identify appropriate candidates for case management, explains services ensuring voluntary agreement of services and maintains a minimum patient caseload in a timely matter.
Certifications
Accredited Case Manager (ACM) - American Case Management Association (ACMA), Certified Case Manager (CCM) - The Commission for Case Manager Certification (CCMC), Registered Nurse (RN) - Arkansas State Board of NursingArkansas State Board of Nursing
Security Requirements
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment Type
Regular
ADA Requirements
Requirements
EDUCATION
Bachelor's degree in Nursing preferred.
LICENSING/CERTIFICATION
Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.
KNOWLEDGE & EXPERIENCE
Minimum four (4) years' clinical practice experience in at least one of the following areas: case management, home health, critical care, medical/surgical, discharge planning, concurrent review, or obstetric/neonatal care.
ESSENTIAL ABILITIES & SKILLS
Independence
Detail oriented
Administrative Process
Affinite CM
Affinite UM
CCI Edits
Collaborative Communications
Critical Reasoning
Cross-Functional Planning
Customer Relationship Management (CRM)
Customer Service Workstation
Deductive Reasoning
Five9
Information Security
Interpersonal Relationship Management
Microsoft Excel
Microsoft Office
Microsoft Outlook
Microsoft PowerPoint
Needs Assessment
Oral Communications
Problem Sensitivity
Researching
Sound Judgment
Support Coordination
Written Communication
Benefits
Health insuranceRemote work options
Additional Information
To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here .
Job Summary
The RN Case Manager plays a critical role in optimizing patient care and resource utilization. The incumbent is responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating comprehensive care plans to meet individual health needs. This role focuses on quality patient outcomes and cost-effective healthcare delivery and may encompass general medical case management or specialize in high-acuity areas and/or high-cost areas such as high-risk obstetrics and neonatal care, chronic disease management, and/or mental health support (excludes Behavioral Health).
Arkbluecross · Arkansas Remote