Care Management Nurse
Remote in WA, OR, UT, ID. Candidates outside of these states will not be considered.
The Care Management Nurse provides clinical care management (such as case management, disease management, and/or care coordination) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member's care to assess, plan, implement, coordinate, monitor and evaluate care as needed.
- Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.
- Assessment: collection of in-depth information about a member's situation and functioning to identify individual needs.
- Planning: identification of specific objectives, goals, and actions designed to meet the member's needs as identified in the assessment.
- Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan.
- Coordination: organization, securing, integrating and modifying resources.
- Monitoring: gathering sufficient information to determine the plan's effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.
- Consults with physician advisors to ensure clinically appropriate determinations.
- Serves as a resource to internal and external customers.
- Collaborates with other departments to resolve claims, quality of care, member or provider issues.
- Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.
- Responds in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
- Provides consistent and accurate documentation.
- Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.
Normally to be proficient in the competencies listed above
- Knowledge of health insurance industry trends, technology and contractual arrangements.
- General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.
- Strong oral, written and interpersonal communication and customer service skills.
- Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.
- Strong organization and time management skills with the ability to manage workload independently.
- Ability to think critically and make decision within individual role and responsibility.
Care Management Clinician would have a/an Associate or Bachelor's Degree in Nursing or related field and 3 years of case management, utilization management, disease management, or behavioral health case management experience or equivalent combination of education and experience. Required Licenses, Certifications, Registration, Etc.
Must have an unrestricted Registered Nurse license and at least 3 years (or full time equivalent) of direct clinical care
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com