The Clinical Nurse Specialist will receive members for review through but not limited to a) inbound calls from members, b) clinical nursing teams, c) providers, d) Behavioral Health facilities and e) Wellness/DM coaches. The Clinical Nurse Specialist will assess the severity of the clinical needs, refer to the Appointment Specialist to assist the member in scheduling an appointment and/or make a referral to the most appropriate TCCI Program and site of service. Additionally, the Clinical Nurse Specialist is responsible for reviewing records of members identified for potential Medical or Behavioral Health intervention via CareFirst analytics and provide/facilitate subsequent referrals to appropriate programs according to CareFirst clinical guidelines.
The Clinical Nurse Specialist is responsible for consistently meeting Service Levels for inbound calls and managing their work fluctuations. In addition, the Clinical Nurse Specialist will engage members as part of initial assessment discussing potential programs and make warm transfers wherever possible.
The Clinical Nurse Specialist will also be responsible for completing other duties as assigned.
Under the oversight of the Director of the Intake, Assessment & Appointment Unit, the essential duties and responsibilities include, but are not limited to, the following:
1. Receive referrals from clinicians and inbound calls from CareFirst Members and follow clinical decision algorithm to assess and reach disposition. Review iCentric Member Health Record as part of assessment of each Member's needs to provide most appropriate advice and or referral to TCCI Program. Assist Members without a Primary Care Provider to select one. Forward inbound member calls to the Appointment team when initial assessment identified that as the clinical need.
2. Reviews identified Member groups to determine if the Member has current needs. Based upon the review and assessment, Members with additional needs will be referred to a Behavioral Health Care Coordinator, an Unattributed Local Care Coordinator, or an Attributed Local Care Coordinator. Assessment and disposition will be documented in iCentric.
3. Maintains expert knowledge of TCCI Programs so that referrals may be made to support the Member. Attend Regional meetings/training as appropriate.
4. Works with leaders responsible for clinical and quality oversight, taking direction and feedback to maintain departmental standards for own individual quality and productivity.
Healthcare background and current licensure as a R.N. is required. BSN preferred.
Minimum 3-5 years clinical experience. Preferably in case management, triage, urgent care, and acute care setting including but not limited to the Emergency Department, ICU, or other critical care areas.
Solid understanding of behavioral health and medical diagnoses.
Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
Must have strong assessment skills with the ability to make rapid connection with Member telephonically.
Must be able to flex effectively and work independently or in a team environment.
Must be able to work effectively with large amounts of confidential member data and PHI.
Must be able to prioritize workload during heavy workload periods.
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed.
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point.
Proven experience in providing excellent customer service to external and internal customers.
Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis.
Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Health Insurance and Call Center Experience, including knowledge of state of the art technology.
Department: PCMH Operations
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: DNP
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
Must be able to work in an office setting, primarily seated talking on the telephone while performing duties for a minimum of 8 hours per work day.
Occasional walking or standing is required. Lift weight up to 25 pounds on occasion.
Hands are regularly used to write, type, key and handle or feel small controls and objects.
Must be able to type and to speak on the telephone simultaneously.
Have the ability to verbally communicate effectively.
Have the ability to actively listen.
Travel to and from the office is required. Travel to other CareFirst locations may occasionally be required. Must provide own transportation.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship