Medicare Advantage Case Management Triage Nurse

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• Make a Positive Impact:
  Your work will directly contribute to the health and well-being of Kansans.
• Family Comes First:
  Total rewards package that promotes the idea of family first for all employees. Paid vacation and sick leave with paid maternity and paternity available immediately upon hire.
• Professional Growth Opportunities:
  Advance your career with ongoing training and development programs.
• Dynamic Work Environment:
  Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.
• Trust and Stability:
  Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.
• Inclusive Work Environment:
  We pride ourselves on fostering a workplace where everyone is valued and respected.

• Base compensation is only one component of your competitive Total Rewards package
• Incentive pay program (EPIP)
• Health/Vision/Dental insurance
• 6 weeks paid parental leave for new mothers and fathers
• Fertility/Adoption assistance
• 2 weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
  
  Health & fitness benefits, discounts and resources

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. Responsible for testing discharge call outreach (DCO) system development as needed.

Responsible for conducting all activities in compliance with State, URAC, HIPAA, DOL, CMS, and MTM goals and/or guidelines.

This position is eligible to work hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

• Collaborate/coordinating with the case managers and management to identify, clinically research and triage potential members for CM.
• Coordinate CM identification activities with case managers and other area staff for optimal efficiency of processes.
• Collaborate with other areas of the company (e.g. health analytics, disease management) to identify and promote management of appropriate Blue Cross and Blue Shield of Kansas (BCBSKS) members and achievement of other corporate goals (e.g. HEDIS/Stars) which may involve participation of the CM area.
• Perform initial clinical review on referred cases.
• Triage referred cases to other programs or resources as needed (e.g. pharmacy, disease management, rare disease management, other wellness programs, etc.)
• Conduct review of medical information without direct supervision. Must determine through independent medical knowledge which cases require CM input or medical consultant expertise. All such determinations must be made under limited time constraints.
• Assist in answering the general CM telephone lines for all lines of business and triaging the calls to the appropriate case manager, Other Area Of The Company, Or Handle As Appropriate.
• Maintain appropriate activity level and case documentation to meet URAC, CMS, group and/or corporate requirements.
• Responsible for performing all job functions 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 emergency department use, etc.).

• Ability to communicate effectively, verbally, in writing, and via telephone regarding confidential and sensitive issues while maintaining a positive professional image.
• Ability to problem solve using analytical reasoning and research.
• Ability to self-direct, self-motivate, make independent decisions, and prioritize/organize daily activities.
• Awareness and understanding of current medical care practices.
• Schedule could require alternative work hours, which may include evenings, weekends or be on call 365 days per year.

• Associate Degree in Nursing (ADN) required.
• Bachelor of S