Integrated Care Manager - Medicare Advantage Job at Blue Cross Blue Shield of Arizona (Phoenix)

Job Description

Integrated Care Manager - Medicare Advantage (prior CM experience working in a health plan)- Remote

Job Responsibility

Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan
Answer a diverse and high volume of health insurance related customer calls on a daily basis
Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests
Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines
Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements
Maintain complete and accurate records per department policy
Demonstrate ability to apply plan policies and procedures effectively
When indicated to assist with team/project functions: Collaborate with team to distribute workload/work tasks
Monitor and report team tasks
Communicate team issues and opportunities for improvement to supervisor/manager
Support/mentor team members
Participate in continuing education and current development in the field of medicine, behavioral health and managed care at least annually
The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements
Perform all other duties as assigned

Requirements

2 year(s) of experience in full-time equivalent of direct clinical care to the consumer
Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D
Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN
Within 4 years of hire as a Care Manager employee must hold a certification in case management from the following certifications
Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC)
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Intermediate skill in word processing, spreadsheet, and database software
Maintain confidentiality and privacy
Advanced and current clinical knowledge
Practice interpersonal and active listening skills to achieve customer satisfaction
Interpret and translate policies, procedures, programs, and guidelines
Capable of investigative and analytical research
Demonstrated organizational skills with the ability to priortize tasks and work with multiple priorities
Follow and accept instruction and direction
Establish and maintain working relationships in a collaborative team environment
Apply independent and sound judgment with good problem solving skills
Navigate, gather, input, and maintain data records in multiple system applications
Conflict Resolution
Represent BCBSAZ in the community

Nice to have

3 year(s) of experience in full-time equivalent of direct clinical care to the consumer (managed care CM experience preferred)
1-2 year (s) of experience working in a managed care organization
Bachelor's Degree in Nursing or Health and Human Services related field of study
Active and current certification in case management from the following certifications
Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC)
Advanced PC proficiency
Knowledge of CPT 2018 and ICD-10 coding
Knowledge of managed care, utilization management, and quality management
Working knowledge of McKesson InterQual, MCG, ASAM, or other nationally recognized criteria
Knowledge of a wide range of matters pertaining to the organizations services and operations
Knowledge of health and/or patient education and behavior change techniques

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Integrated Care Manager - Medicare Advantage

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