Job Description

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

This position will engage at risk members to improve health and financial outcomes through analysis of needs, design, and delivery of interventions. The Nurse Care Manager educates members to understand innovative benefit structures that promote transparency and affordability and empowers consumers to make informed decisions regarding their healthcare options, coverage, and financial risk. This role supports members in developing self-management skills and adopting positive behavior changes, identifies and addresses barriers to member’s adherence to standards of evidence-based medicine. Identifies resources to assist members in achieving their personal health goals, and proactively incorporates lifestyle improvement and prevention opportunities into member interventions. The Nurse Care Manager assists members in navigating the complex health care settings and ensures they get the support they need to optimize their overall health status.

Candidates applying to this position must live within driving distance of the Lincoln, Nebraska metro and required to be onsite at Bryan Hospital East and Bryan Hospital West.

What you'll do:

• Screen and triage members for levels and types of nurse advocacy and medical management programs, including but not limited to: member outreach initiatives, Case Management, and Nurse Health Coaching for chronic conditions.
• Follow the nursing process of assessment, planning, implementation, and evaluation of member-centric goals and interventions for members enrolled in the case management program.
• Conduct clinical assessments and engage members through a variety of approaches that will include telephonic and mobile application interventions depending on the model of care delivery. Clinical assessments address the health and wellness needs of BCBSNE members using a broad set of clinical and motivational interviewing skills with the goal of effecting members’ self-management and positive behavior changes.
• Function as a Nurse Care Manager for members with medical needs with the level of engagement ranging from coaching interventions to intensive case management interventions. Across the continuum of services, the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making.
• Identify potential discharge complications or preventable readmissions and follow-up with members after return home to ensure member is able to obtain medically necessary care, understands discharge instructions and plan of care, understands warning signs of complications and knows what actions to take to address changing health status.
• Collaborate and consult with healthcare providers, members, internal team of clinical support specialists, Utilization Management, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives; conducting prospective, concurrent and retrospective utilization reviews for medical necessity as needed.
• Act as a resource within the department and to other departments regarding medical management issues and activities, including attending presentations and onsite group events.
• Educate members about their benefits and coverage, and guide members to appropriate programs, community resources, and in-network providers.
• Maintain compliance requirements by knowing, understanding, and adhering to URAC accreditation standards and other regulatory requirements.
• Responsible for maintaining professional licensure and practicing within the scope of licensure.
• Responsible for completion of special projects, examples may include training new hires, provider outreach, project work, peer mentor, new system implementation, and system testing.
• Hours: 8am-5pm Monday to Friday with some flexibility. This position doesn't have any on-call, weekend or holiday rotation.

To be considered for this position, you must have:

• Associate's Degree in Nursing
• The Nurse Care Manager must hold an active, current, and unrestricted Registered Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates.
• Three (3) years clinical nursing practice experience.

The strongest candidates for this position will also possess:

• Demonstrated previous experience working in Medicare Advantage and Managed Care organizations.
• Bachelor's degree in healthcare field.
• Certification in Case Management, Managed Care, and/or Health Coaching.
• Clinical experience in multiple levels of care.
• Experience in discharge planning, Health Coaching, case management, or disease management.
• Knowledge of accreditation standards and regulatory requirements.
• Medicaid and Medicare Care Management experience.

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.