Case Manager


Mid Level


$55.000 - $70.000

14 Oct → 13 Nov

Blue Cross and Blue Shield of North Carolina

Durham, NC, USA

About Company

Blue Cross NC is a fully taxed, not-for-profit North Carolina company with major operations centers in Durham, Fayetteville and Winston-Salem. We employ about 4,800 North Carolinians1 and serve our customers and communities of more than 3.81 million members, including almost 1.1 million served on behalf of other Blue Plans.2 Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association.
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Job Description

The Case Manager / Health Coach coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resource outcomes.

Serve as a team member on a multidisciplinary team that monitors utilization patterns; identifies and facilitates appropriate health care service delivery for selected members, providers, procedures, and/or diagnoses; and improves the quality and cost efficiency of care and service. The application of the Case Manager or Health Coach’s knowledge and clinical skills will vary across the Health Care division, dependent on focus areas identified by the business area supported.

Job Responsibilities

  • Outreach - Outreach to members identified as high risk, high cost, or high utilization cases. Encourage pro-active intervention to limit expense and encourage positive outcomes.
  • Assessment - Perform a comprehensive assessment of the member’s health status, educational, and level of support needs.
  • Planning - Develop a member-centric care plan which includes a self-management plan tailored to member’s needs, and identification of barriers to meeting goals or plan of care.
  • Planning - Utilize community resources and funding sources in the development of the plan of care.
  • Perform ongoing monitoring and management of member including: scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity.
  • Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care). Review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible.
  • May evaluate medical necessity and appropriateness of services as defined by department.
  • Document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome.
  • Complete all correspondence related to case management, including all calls and faxes with phone and fax numbers noted. Obtain consents as indicated.

Requirements / Qualifications

  • RN with Associate’s degree or Bachelor of Science in Nursing (BSN).
  • Minimum of 3 years full-time direct clinical experience in an acute medical or acute surgical setting.
  • Proficiency with a Microsoft Windows operating system
  • Must have valid license to practice nursing within the US and have started application for NC nursing license.
  • Prefer Certification for Case Management

How To Apply

Apply through GoRemotely.

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