Medicare Advantage Case Management Triage Nurse

With the support of the lead Medicare Advantage nurse coordinator, carries primary and independent responsibility for the day-to-day activities of researching, reviewing, processing, initial screening and triage of members identified in the resource utilization programs as well as those identified from any other source. Responsible for appropriate identification and referral of members for potential case management (CM) intervention. Responsible for testing discharge call outreach (DCO) system development as needed. Responsible for conducting all activities in compliance with State, URAC, HIPAA, DOL, CMS, and MTM goals and/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

Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

Why Join Us?

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

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

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

• Stability: 80 years of commitment, compassion and community

• Flexibility: options to work onsite, hybrid or remote available

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

• 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 ind