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Blue Cross and Blue Shield of Kansas City · 6 hours ago

RN - Clinical Account Manager, High-Cost Claimants

Kansas City, MO

Full-time

Hybrid

Mid Level

3+ years exp

Blue Cross and Blue Shield of Kansas City is committed to providing health, financial, and lifestyle benefits. The RN - Clinical Account Manager will present data-driven insights to client groups and insurance brokers to identify high-cost claimants and positively impact medical cost trends.

Association

Comp. & Benefits

Responsibilities

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

Qualification

RNBSNCase ManagementCCMPopulation HealthClient ServiceData AnalysisCommunication SkillsCollaboration

Required

RN, BSN with a minimum of 3 years of experience

Previous Case Management Experience required

CCM Required within 3 years of hire

Preferred

Advanced degree

Previous experience with Health Plan

Benefits

Comprehensive medical, dental and vision benefits

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

Company

Blue Cross and Blue Shield of Kansas City

Blue Cross and Blue Shield of Kansas City (Blue KC) is an independent licensee of the Blue Cross Blue Shield Association and a not-for-profit health insurance provider serving more than one million members in 32 counties in greater Kansas City and northwest Missouri and Johnson and Wyandotte counties in Kansas.

Founded in 1982

Kansas City, Missouri, USA

1001-5000 employees