Managed Care Case Manager, RN - Remote

Job Summary:
This key position is responsible for assisting members within a geographical (local, statewide and/or other) area make effective health care choices for self-management of their acute and /or chronic condition(s). Utilizing a member-centric approach they assist members and their families understand and manage their disease process by: reinforcing the physicians' plan of treatment, promoting healthy behaviors and lifestyle changes, and providing education and tools to promote self- management to improve health outcomes and reduce overall costs. Individual care plans are developed in collaboration with the Physician, Member/Care Giver, Families and the Care Team. Ongoing coaching, monitoring and evaluation of care plans will be done face to face with the member, telephonically, digital engagement or electronically through email and member and provider portals.

Essential Functions:

• The essential functions listed represent the major duties of this role, additional duties may be assigned.
• Engage Members telephonically, using digital engagement tools and/or face to face at Florida Blue Retail Centers, hospitals, etc. with a focus on health coaching and member education. Facilitate access to care and resources to meet the member’s health care needs. Provide education and tools to promote self-management.
• Plan, implement, coordinate and monitor Case Management activities that may include acute and non-acute services, outpatient services, behavioral health and / or community resources.
• Facilitate care for high risk members across the continuum of the health care experience, including care transitions, coordination of community and social service and coordinating with other value-based organizations, providers as needed.
• Close gaps in care 
• Conduct Medication Reconciliation
• Collaborate with Member, Member’s Physicians, Plan Medical Directors, Managers, Local, Regional and Specialty team members as well as other functional areas to assist the member to meet their health care goals. 
• Promote healthy lifestyles, assist in strengthening the patient-physician relationship, encourage behavior and lifestyle changes to realize a better quality of life, for individuals with identified chronic conditions, costly and/or catastrophic illnesses.
• Assist Members and their physicians to navigate through the health continuum, educate regarding benefits, identify candidates for Care Programs and provide information pertaining to the network and network access. 

Required Work Experience:

RN - Registered Nurse - Active and Unrestricted State Licensure And/Or Compact State Licensure  
2+ years related work experience. Experience Details: Communicating and building relationships with members/providers/employers both telephonically as well as live 
Related Bachelor’s degree or additional related equivalent work experience 
Experience with influencing and motivating individuals to change health behaviors 
Knowledge and/or experience with population health 
Experience in two or more of the following: home health care, utilization review, discharge planning, disease/ case management 
Experience working with Managed Care products, benefits and services 
Experience in planning, implementing coordinating and monitoring activities that focus on acute and non-acute services, outpatient services and/or community resources for all lines of business 
Non-traditional working hours to meet the member's availability 
Basic to intermediate experience in MS Word, Excel, tablet and/or smartphone .Basic technology skills with digital tools and apps. 
Travel up to 30% (subject to change) for on-site member/provider/employer meetings, events or manager requests with occasional overnight stays 
Must have valid driver's license and reliable transportation

Preferred Education
Bachelor’s degree in a related field 
 

Preferred Licenses and Certifications:
CCM - Certified Case Manager 
 

Additional Preferred Qualifications:
Bilingual English/Spanish and/or Creole  Direct clinical experience (3-5 years)  Experience working remotely (i.e. home office) 
 

General Physical Demands:
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. 
 

Physical/Environmental Activities:
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally 

What We Offer: 
As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care