Medicare Advantage Case Management Triage Nurse

Job Title

Medicare Advantage Case Management Triage Nurse

The Medicare Advantage Case Management Triage Nurse is primarily and independently responsible for the day‑to‑day activities of researching, reviewing, processing, initial screening and triage of members identified in the resource utilization programs as well as those identified from any other source. Responsible for appropriate identification and referral of members for potential case‑management (CM) intervention, testing discharge call outreach (DCO) system development as needed, and conducting all activities in compliance with State, URAC, HIPAA, DOL, CMS, and MTM goals and/or guidelines.

The position is eligible to work hybrid or onsite under the telecommuting policy. Applicants must reside in Kansas or Missouri or be willing to relocate.

• Collaborate and coordinate with case managers and management to identify, clinically research, and triage potential members for CM.
• Coordinate CM identification activities with case managers and other staff for optimal process efficiency.
• Collaborate with health analytics, disease management, and other areas to identify and promote management of appropriate BCBSKS members and achieve corporate goals such as HEDIS/Stars.
• Perform initial clinical review on referred cases.
• Triage referred cases to other programs or resources as needed.
• Conduct medical information review without direct supervision, determining which cases require CM input or medical consultant expertise under time constraints.
• Assist in answering general CM telephone lines and triage calls appropriately.
• Maintain activity level and case documentation to meet URAC, CMS, group, and/or corporate requirements.
• Operate within the scope of the Kansas Nurse Practice Act.
• Deliver onsite training and orientation for new department employees.
• Conduct resource utilization program activities (e.g., post‑discharge member contact, avoidable ED use).

• Effective verbal, written, and telephone communication regarding confidential and sensitive issues while maintaining a professional image.
• Analytical reasoning and research to problem‑solve.
• Self‑directed, self‑motivated, independent decision‑making, and prioritization of daily activities.
• Awareness of current medical care practices.
• Willingness to work alternative hours, evenings, weekends, or be on call 365 days per year.

• Associate Degree in Nursing (ADN) required.
• Bachelor of Science in Nursing (BSN) preferred.
• Registered nurse with a minimum of three years RN clinical nursing experience required, acute medical/surgical preferred.
• Current, active, and unrestricted Kansas RN License.
• Experience with government programs preferred.

95% of daily activity requires use of computer and/or telephone.

$73,920–$92,400annually. Exempt Grade
15. The compensation range is a good faith estimate and may vary above or below the stated amounts. All offers are reviewed to ensure fair, equitable pay aligned with the candidate’s skills, education, experience, and training.

• Health/Vision/Dental insurance
• 6weeks paid parental leave for new mothers and fathers
• Fertility/Adoption assistance
• 2weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
• Health & fitness benefits, discounts and resources

Blue Cross and Blue Shield of Kansas provides equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy, national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information, military or veteran status, family or parental status, or any other characteristic protected by applicable law. Blue Cross and Blue Shield of Kansas conducts pre‑employment drug screening, criminal conviction check, employment verifications, and education as part of a conditional offer of employment.