[Remote] Clinical Navigator (Remote)

Note: The job is a remote job and is open to candidates in USA. CareFirst BlueCross BlueShield is seeking an experienced Clinical Navigator (RN) to support inpatient utilization and care management. The role conducts concurrent reviews, determines medical necessity and appropriate levels of care, coordinates discharge planning, and collaborates with members, families, providers, hospital teams, and medical directors to promote safe transitions.

Responsibilities

• Utilize clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services. Engages telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members' medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home
• Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care. Applies sound clinical knowledge and judgment throughout the review process. Follows member benefit contracts to assist with benefit determination
• Makes referrals to other care management programs as appropriate for chronic, long-term care coordination
• Works collaboratively with hospital teams to develop positive working relationships to decrease provider abrasion and improve the member experience

Skills

• Bachelor's Degree in Nursing OR on lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience
• RN - Registered Nurse - State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or Washington, DC
• 5 years clinically related experience working in Care Management, Home Health, Discharge Coordination and/or Utilization Review
• Strong interpersonal skills and the ability to engage in a member facing environment (telephonically) while at the same time building relationships and partnerships with hospital care team and alternative care delivery partners to meeting member/enrollee needs
• Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point
• Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis
• Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations
• Knowledge of available community resources and programs
• Basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits)
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence
• Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging
• Must be eligible to work in the U.S. without Sponsorship
• Direct experience with utilization review in a healthcare payor organization
• Knowledge and experience with MCG
• Experience working with Commercial Employee group member and Medicare/Medicaid enrollees and benefits contracts
• CCM certification
• MCG certification

Benefits

• Comprehensive benefits package, subject to eligibility requirements
• Various incentive programs/plans, subject to eligibility requirements
• 401k contribution programs/plans, subject to eligibility requirements
• Remote work from within the greater Baltimore metropolitan area, with periodic attendance at a CareFirst location for meetings, training and/or other business-related activities

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