Summary:

Utilizing key principles of case management, the RN Specialist will research and analyze the member’s health needs and health care cost drivers and will work closely with an interdisciplinary care team to ensure members have an effective plan of care that leads to optimal, cost-effective outcomes. Leveraging clinical expertise, strong critical thinking skills and a keen business sense, the RN Specialist will work closely with the member and their family to avoid unnecessary hospitalizations and emergency department utilization, optimize site of care whenever possible, and ensure evidence-based treatment is being applied. An experienced case manager with managed care experience will be successful in this role.

Accountabilities:

1. Receives referral for member identified with high cost, complex medical conditions and telephonically outreaches to the member, family and providers to engage in complex case management program.
2. Conducts clinical assessments with members and providers utilizing motivational interviewing; gathers, analyzes, synthesizes and prioritizes member needs and opportunities based upon the clinical assessment and research and collaborates with the interdisciplinary care team to develop a comprehensive plan of care.
3. Collaborates and communicates with the health care team; e.g. member, family, designated representative, health care provider on a plan of care that produces positive clinical results and promotes high–quality, cost effective outcomes.
4. Identifies relevant BCBSMN and community resources and facilitates program and network referrals.
5. Monitors, evaluates, and updates plan of care over time.
6. Ensures member data is documented according to BCBSMN application protocol and regulatory standards.
7. Maintains outstanding level of service at all points of customer contact.
8. Understands the strategic and financial goals of the department, complex care management teams, and the enterprise
9. Knowledgeable of health plan operations (e.g. networks, eligibility, benefits)
10. Promotes innovative solutions to improve day to day functions and enhance the overall operation of the department.
11. Collaborates with interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member’s needs and health care cost drivers.
12. Engage providers telephonically in reviewing and understanding treatment plans, including alignment with benefits and medical reimbursement policies to facilitate optimal treatment plans, care coordination, and transition of care between settings. 
13. Identifies and implements cost saving opportunities to ensure optimal and cost-effective health outcomes.