PURPOSE OF THE JOB

· Responsible for promoting continuity of care through a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates care options and services available to members through their benefit plan that meet the individuals’ health care needs while promoting quality, cost effective outcomes. This job description is primary for case management functions but can assist with utilization management if a business need arises.

Required Qualifications

1. Required Work Experience

· 2 year(s) of experience in full-time equivalent of direct clinical care

2. Required Education

· 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

3. Required Licenses

· 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.

4. Required Certifications

· Within 3 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).

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

· 3 year(s) of experience in full-time equivalent of direct clinical care to the consumer

· 1-2 year (s) of experience working in a managed care organization

2. Preferred Education

· Bachelor’s Degree in Nursing or Health and Human Services related field of study

3. Preferred Licenses

· N/A

4. Preferred Certifications

· 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).

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

· 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.

COMPETENCIES

REQUIRED COMPETENCIES

1. Required Job Skills

· 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

2. Required Professional Competencies

· 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 prioritize 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

3. Required Leadership Experience and Competencies

· Conflict Resolution

· Represent BCBSAZ in the community

PREFERRED COMPETENCIES

1. Preferred Job Skills

· Advanced PC proficiency

· Knowledge of CPT 2018 and ICD-10 coding

2. Preferred Professional Competencies

· 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

3. Preferred Leadership Experience and Competencies

· N/A

CORPORATE RESPONSIBILITIES

Comply with BCBSAZ corporate and departmental policies and procedures, including, but not limited to Code Blue, Compliance, HIPAA, Computer Responsibility, Accreditation Standards, Attendance, Staff Qualifications and Quality Management Accountabilities.