Note: The job is a remote job and is open to candidates in USA. CareFirst BlueCross BlueShield is seeking a Clinical Navigator (RN) to manage the transition of patients from inpatient care to home or other levels of care. The role involves conducting concurrent reviews of patient care, collaborating with healthcare teams, and ensuring appropriate care management and discharge planning for members.

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 in 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
• Knowledge and experience with MCG
• Experience working with Commercial and Federal Employee Program employee group member and Medicare/Medicaid enrollees and benefits contracts
• CCM certification
• MCG certification

Benefits

• Comprehensive benefits package
• Various incentive programs/plans
• 401k contribution programs/plans

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