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Position Description

Arkansas Blue Cross and Blue Shield - EXEMPT POSITION DESCRIPTION

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Position:  Case Management Nurse
Reports To: 
Division:  Enterprise Med Mgmt (0047)
Company:  ABCBS
Location:  Texarkana
Job Code:  030416
Min Salary:   56800
Date:  4/9/2013

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Position Specific Requirements: This position will be located in the Southwest Regional Office in Texarkana.


Job Summary
This position is responsible for proactive case management initiating a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health needs/education, utilizing plan benefits and community resources.  The incumbent will utilize communications and available resources to promote quality for the most effectives outcomes, member self-management education (may include primary prevention, behavior modification programs and compliance), etc.  The incumbent will actively participate in Quality Improvement Programs.

Nature & Scope
The incumbent’s charge is to work with referrals from multiple sources to identify appropriate candidates for case management.

Referral sources:
• Utilization Management Vendor
• Hospitals
• Trigger Diagnoses
• Physicians
• Disease Management Programs
• Health Coaches
• Reports
• Medical records
• Medical Audit and Review
• Marketing
• Employer Groups
• Agencies
• Customer Service
• Health Risk Assessments
• Member

The incumbent will facilitate formation of health care teams to include patients, families/caregivers, physicians, and all other ancillary providers and must have the ability to communicate at all levels, often in a highly charged, emotional environment.

This position works closely with the Quality Program Manager (QPM) and Medical Directors for the implementation of medical management programs across all lines of business.


Skills, Knowledge and Abilities

1.  Above average interpersonal skills.
2.  Problem solving skills.
3.  Ability to organize workflow and distribution.
4.  Ability to make decisions based on facts and assume responsibilities for these decisions.
5.  Possess broad knowledge of current trends in health care and knowledge of medical economics.
6.  Above average math skills.
7.  Possess broad knowledge of statewide resources.
8.  Ability to work closely with physicians, provider community and members.
9.  Communicate effectively both orally and in writing, with all levels within the Region, the provider community,         regulatory agencies and the general public.
10.  Establish goals and plan effective methods to achieve these goals.
11.  Medical record review skills.
12.  Assess the medical / psychosocial environment of the patient.
13.  Participate in inter-region / corporate standards / protocol development and Best Practice identification.







Minimum Job Requirements
1. Arkansas Registered Nurse license and in good standing with clinical practice experience.

2. CCM Certification required. If certification not obtained prior to employment, must be eligible to sit for exam by second year of employment.

3. Bachelors (or higher) degree in a health related field preferred.

4. Experience in case management, home health, critical care, medical/surgical, social work, discharge planning or concurrent review, preferred.

5. Marketing experience preferred.

6. Prefer supervisor / management experience.


Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1. Facilitate appropriate cost effective and cost containment measures.
2. Adhere to Enterprise Case Management Standards.
3. Practice case management within the scope of licensure.
4. Cooperate and work effectively with all regional and departmental staff to facilitate services to members and providers of care.
5. Remain current with medical and surgical procedures, products, services, and drugs by attending CMN meetings, conferences, home studies and in-service training.
6. Identify appropriate alternate care settings and community resources.
7. Actively participate in Quality Improvement program.
8. Provide education to provider community, groups and hospitals to facilitate understanding of case management program.
9. Prompt review of case findings, as essential piece to assure timely transfer to alternative care.
10. Work collaboratively with hospital discharge planners, home care providers and community resources to establish CM plan and identify the appropriate setting.
11. Contact member and physician explaining case management services, ensuring that all parties involved agree to voluntary case management services.
12. Monitor contractual and case by case negotiations with providers for quality of care issues, cost effectiveness, accessibility, and provided levels of service utilizing contracted providers when possible.
13. Must be able to maintain a patient caseload per company Policy and Procedure.
14. CM Nurse must maintain case documentation according to URAC standards between 95-100% based on random sampling of charts on a monthly basis.
15. Work referrals daily (to satisfaction of Manager).
16. Work with Marketing dept. to educate groups or individuals regarding proactive case management.
17. Maintain continuous, effective communication between regions regarding case management of multi-regional cases.
18. Maintain continuous, effective communication with internal and external vendors and community resources.
19. Remain visibl in the community, hospitals/facilities, etc. promoting case management and other medical management programs and conduct onsite home visits when appropriate.


Goals the Case Manager Nurse will strive to achieve include:
• Assist the member and family to achieve optimum functioning.
• Coordinate the delivery of physician ordered services as well as community services, decrease fragmentation, and assist with appropriate use of resources.
• Enhance quality of life for the individual and family.
• Support the physician/patient relationship and plan of care.
• Improve and facilitate interdisciplinary communication and planning.
• Help to strengthen the family unit to cope with catastrophic and/or chronic illness.
• Maximize member health by increasing health education that promotes wellness despite chronic illness.
• Proactively identify problems / needs, and coordinate services that provide appropriate high-quality care to meet the individual needs of the member and family.
• Emphasize prevention of exacerbations and complications, using evidence-based practice guidelines, and patient empowerment strategies.

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