Clinical Nurse, Case and Disease Management - High Cost Claims

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include :

Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

Annual incentive bonus plan based on company achievement of goals

Time away from work including paid holidays, paid time off and volunteer time off

Professional development courses, mentorship opportunities, and tuition reimbursement program

Paid parental leave and adoption leave with adoption financial assistance

Employee discount program

Job Description Summary :

Utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote optimal, cost-effective outcomes. Transplant only : Provides prior authorization for, coordinates, and individually manages all member transplants. Acts as an internal and external customer resource for interpretation of transplant benefits and transplant-related claim adjudication. Serves as a company expert on current and future transplant types. The candidate for this position must reside in the Kansas City metropolitan area.

Job Description

• Completes member assessments by collecting and analyzing information across the seven domains of health and develops and implements individualized care plans with appropriate interventions in a culturally sensitive way. Uses standardized tools to complete assessments in the areas of clinical, functional, financial, support system, psychosocial and cognitive and environmental realms.
• Monitors effectiveness of plan of care by gathering sufficient information from relevant sources in order to intervene, as appropriate, to improve health outcomes. Determines appropriate intervals for monitoring plan of care. Utilizes internal, community and other healthcare resources to maximize outcomes.
• Acts as liaison between member, employer, providers, support system and BlueCross BlueShield of Kansas City. Works with multiple members of the healthcare team to foster continuity and coordination of care.
• Prioritizes interventions based on clinical need and readiness to change. Educates and works with members at different educational and health literacy levels. Utilizes clinical knowledge and critical thinking skills to individualize evidence based interventions. Assesses the member's need for education and tailors teaching to the member's knowledge level and learning style.
• Meets individual quality performance standards and annual targets for program performance as mutually agreed to by management team to maximize program value. Ensures compliance with applicable URAC and NCQA guidelines and state and federal regulations.
• Meets targets for program performance, such as monthly productivity and annual caseload requirements as mutually agreed to by management team to maximize program value.
• Schedules time effectively. Works with minimal supervision. Handles multiple projects simultaneously. Prioritizes work appropriately.

Additional duties for Transplant only :

Minimum Qualifications

Preferred Qualifications

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.