RN - Clinical Account Manager, High-Cost Claimants

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: This Registered Nurse presents data-driven insights and clinical health information to large self-funded client groups and insurance brokers/consultants to identify those members that are high-cost or potentially high-cost claimants as quickly as possible. Understands Blue KC healthcare programs, benefits and services, medical policy, provider network/reimbursement strategies, and industry best practices to positively impact medical cost trends. The candidate for this position must reside in the Kansas City metropolitan area.

Job Description

• Partner with account team members to provide best-in-class member and client service.
• Educates clients, brokers, consultants, and internal associates and articulates the value of Blue KC's approach to managing care delivery to the employer groups.
• Serves as a key subject matter expert and strategic partner for the Commercial Sales organization and regularly attends client meetings (with benefits managers and executives) to review health outcomes and cost information.
• Actively monitors care management identification and segmentation results, engagement rates, and Performance Guarantees to address any issues identified.
• Completes the requests of the internal and external stakeholders promptly, addressing key stakeholders' needs with a sense of urgency, prioritization, reprioritization, and flexibility to meet business needs.
• Contacts Strategic Client Consultants to discuss special member situations and determine if an exception or special consideration (e.g., benefits) should be made.
• Participate in existing client utilization and renewal meetings or tell our clinical value story as requested.
• Track, monitor, and identify clinical metrics for client population, and work with stakeholders to mitigate as appropriate.
• Leverage various clinical reports (e.g., High-cost claimant reports, early warning reports, census reports, case management participant reports, etc.) to identify potential high-cost claimants, opportunities for member engagement, and ensure the member is in the correct place within the care management continuum.
• Expert at reviewing and presenting population health information, ability to investigate large employers' high-cost utilizers as well as key cost drivers from a clinical perspective
• Communicates the value Blue KC offers using data from the member/employer group perspective.
• Provide time-sensitive clinical reporting on requests for employer groups received by standard request processes for Case Management (CM) from Underwriting, client managers, sales team, brokers, etc.
• Collaborates with the Clinical Operations leadership team to develop strategies and identify adjustments needed to meet established goals.
• Collaborates with the Senior Healthcare Consultants, Strategic Client Consultants, Onsite nurses, Wellness Coordinators, and key personnel from Employer Groups to provide monthly and/or quarterly reporting to the Employer Group to monitor trends and ensure targets and expectations are met.
• Collaborates with Underwriting by completing ad hoc reporting requests that include providing clinical summary and details on the projection of future costs to analyze underwriting risk.
• Collaborates with Medical Directors, Pharmacists, Behavioral Health, and nurses during rounds sessions discussing high cost, high length of stay, high-cost drug management, and opportunities for steerage to a lower-cost plan of care.
• Oversee program and group implementations for assigned groups, RFP responses, internal and external client audits, program presentations for clients, and program materials creation and maintenance.
• Participates in cultural trainings to review the Case Management program, engagement techniques, cost containment strategies, and opportunities for collaboration with employer's health clinics/staff
• Communicates and co-leads Employer Group/Broker meetings reviewing early warning reports and high-cost claimant data on cost drivers, future cost projection, case management engagement, and interventions for cost containment.
• Regular communications with Blue KC Clinical Operations staff to ensure identified members are addressed as needed.
• Keep Population Health leaders and team members abreast of all employer group information, including incentives, penalties, unique workflows, employer group wellness offerings, and/or benefit updates.
• Build and manage strong client and third-party relationships.
• Support general business needs and operations, as required.
• Ability to resolve numerous and undefined issues requiring detailed information gathering, analysis, and investigation to understand the problem; difficult and moderately complex problems typically impact multiple departments or specialties and are usually solved through drawing from prior experience and analysis of issues. Develops new perspectives and innovative approaches to existing problems.
• 5% or more travel to client and business meetings.
• Remote working opportunities when not at client or business meetings.

Minimum Qualifications

• RN, BSN with a minimum of 3 years of experience
• Previous Case Management Experience required
• CCM Required within 3 years of hire

Preferred Qualifications

• Advanced degree
• Previous experience with Health Plan

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. Apply tot his job Apply To this Job