The High-Cost Claim team at BCBST is seeking a compassionate and highly skilled RN Case Manager to support members with advanced and multifaceted healthcare needs. In this role, you will provide comprehensive, member-centered care for individuals with complex and chronic conditions, including high-risk diagnoses, through a proactive, advocacy-driven approach. You will collaborate across multidisciplinary teams to coordinate care, reduce barriers, and improve health outcomes while supporting cost-effective utilization of services and reducing unnecessary ED and inpatient utilization. Success in this position requires the ability to manage a dynamic caseload with strong critical thinking, attention to detail, and exceptional telephonic and digital communication skills. The ideal candidate brings a strong clinical foundation combined with care coordination expertise, including: • Experience in acute care settings such as ED, ICU, or Med-Surg • Background in case management, transitions of care, or discharge planning Experience supporting members with complex needs is highly valued, including: • Chronic conditions (e.g., CHF, COPD, diabetes) • Behavioral health needs • Home and community-based care • This experience strengthens the ability to develop effective discharge plans and prevent avoidable readmissions. Candidates should also demonstrate the ability to: • Assess and manage complex needs in a telephonic and digital environment • Navigate care across the continuum • Effectively engage members to drive adherence and outcomes • Strong technical proficiency is essential, along with a willingness to leverage enterprise-approved digital and AI tools to enhance care delivery, documentation, and operational efficiency. Job Responsibilities • Supporting utilization management functions for more complex and non-routine cases as needed. • Serving as a liaison between members, providers and internal/external customers in coordination of health care delivery and benefits programs. • Overseeing highly complex cases identified through various mechanisms to ensure effective implementation of interventions, and to ensure efficient utilization of benefits • Performing the essential activities of case management: assessment: planning, implementation, coordinating, monitoring, outcomes and evaluation. • Digital positions must have the ability to effectively communicate via digital channels and offer technical support. • Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions. • Various immunizations and/or associated medical tests may be required for this position. • This job requires digital literacy assessment. Job Qualifications License • Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
