Blue Cross Blue Shield of North Carolina

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Case Manager (High Risk Pregnancy)

at Blue Cross Blue Shield of North Carolina

Posted: 9/24/2019
Job Status: Full Time
Job Reference #: RQ0005092
Keywords: healthcare, health

Job Description

Additional Locations:

Job Description

The Case Manager coordinates the care and services of high risk pregnancy populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resource outcomes.

  • Serve as a team member on a multidisciplinary Health Care Coordination team that monitors utilization patterns; identifies and facilitates appropriate health care service delivery for selected members, providers, procedures, and/or diagnoses; and improves the quality and cost efficiency of care and service.
  • Perform a comprehensive assessment of the member’s health status, educational, and level of support needs. The assessment includes condition specific issues, clinical history, medications, activities of daily living, mental health status, cognitive functioning, life planning activities, cultural and linguistic needs, caregiver support and resources.
  • Develop a member centric care plan which includes long and short term goals, a self management plan tailored to member’s needs, and identification of barriers to meeting goals or compliance to plan of care.
  • Perform ongoing monitoring and management of member including: scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation to MD, MSW, HLB, etc; assessment of progress towards goals, modification of plan/goals as needed, nurse contact at least every 30 days, complete documentation of calls and faxes with phone and fax numbers
  • Evaluate and facilitate care provided to members as they move through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care).  Review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options.
  • Identify high risk, high cost, or high utilization cases.  Encourage pro-active intervention to limit expense and encourage positive outcomes.
  • Maintain awareness of community resources and funding.  Utilize resources and funding sources in the development of the case management plan.
  • May negotiate and secure contractual arrangements for provision of non-contracting providers. 
  • Collaborate with primary care physician, On-Site Medical Care Coordinator, Discharge Services, Medical Director, Episodic Care Managers, the member, family members and other members of the health care team to develop and/or coordinate plans of treatment and appropriate discharge plans.  This includes knowledge of disease process, and understanding of family dynamics, as they relate to the discharge planning/case management process.
  • Document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome.  Complete all correspondence related to case management.  Obtain consents as indicated.  Analyze and report case management activity according to department policy.
  • Authorize appropriate services as defined by the department. Consult the medical director as appropriate. Refer cases that do not meet criteria to the Medical Director.  May Issue denials according to department protocols. Document outcome of reviews. Negotiate and secure contractual arrangements for provision of non-contracting providers. Ensure medical necessity reviews and determinations meet all requirements imposed by regulatory agencies such as NCDOI, NCQA, Federal, etc.  FEP CM’s do not authorize acute rehabilitation inpatient care.  This is the function of the ECM staff.  FEP CM’s collaborate with ECM’s as appropriate, but are not responsible for the actual process.

Hiring Requirements

  • RN Diploma, RN Associate’s degree or Bachelor’s of Science in Nursing (BSN) degree.
  • Minimum of 3 years full time direct clinical experience in an acute medical or acute surgical setting.
  • Proficiency with a Microsoft Windows operating system
  • Must have valid license to practice nursing within the US and have started application for NC nursing license.
  • Must be able to work until 7:30 pm at least 1 night per week and 9am -1pm 1 Saturday per month

Commercial Care Management:

Certified Case Manager (CCM) certification is required within 2 years of employment. 

FEP and Senior Segment: 

Certified Case Manager (CCM) certification is required within 3 years of employment. 

Hiring Preferences

  • The incumbent must possess medical management/clinical decision-making skills and  sound skills in assessing, planning and managing member care
  • High Risk Pregnancy Case Management experience preferred
  • Advanced assessment and teaching skills.
  • Problem solving skills. 
  • Familiarity with legal terminology and liability issues and ability to handle ethical or risk management issues. 
  • Utilization and Quality Management/Outcomes experience preferred.
  • Previous work experience with a managed care organization or provider is also preferred.
  • Prior experience in case management, home health, discharge planning, or Concurrent review.
  • Excellent communication and interpersonal skills with all levels of internal and external customers necessary.  
  • Individual must be self-motivated/self-directed.  
  • Must possess the abilities to work independently, demonstrate effective time management skills, and to prioritize effectively. 
  • The ability to deal effectively with change within the unstructured nature of case management and remain focused.
  • Demonstrates creativity, critical thinking, counseling, interviewing, negotiating, and research skills. 
  • Certified Case Manager (CCM) certification preferred.

Senior Segment:

Prior experience in a variety of health care settings is preferred.

Certified Case Manager (CCM) preferred. .

Experience with managing and coordinating care for patients who have multiple co-morbidities is preferred.

Experience in responding to the diverse needs of the Medicare population, which includes both over 65 and under 65 aged adults.    

Commercial Care Management:

Multi-State Licensure preferred.


Prior experience in a variety of health care settings is preferred

Experience with managing and coordinating care for patients who have multiple co-morbidities is preferred.

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina. Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

Our company is a not-for-profit with headquarters in Durham and major operations in Winston-Salem and Fayetteville. In all we employ more than 4,900 North Carolinians and serve more than 3.9 million customers.

Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Third Party Staffing Agencies

Blue Cross NC does not accept unsolicited resumes from any source other than directly from candidates. For the protection of all parties involved in the recruiting process, resumes will only be accepted from recruiters/agencies if a signed agreement is in place at the inception of the recruiting effort and authorized for a specific position. Unsolicited resumes sent to Blue Cross NC from recruiters/agencies do not constitute any type of relationship between the recruiter/agency and Blue Cross NC and do not obligate Blue Cross NC to pay fees if we hire from those resumes.

Posted 30+ Days Ago

Full time