Clinical Navigator (Remote)

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information

The Inpatient Management Post Acute Clinical Navigator (RN) manages the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both case management and utilization management including proficiency in MCG to determine medical necessity, appropriate level of care, and case management to engage members, their families and other support systems in discharge planning. The role will function as a liaison with the facility Post-Acute Care team including case managers, social workers, and discharge planners to ensure CareFirst members receive the appropriate level of care and partner to address any potential barriers to discharge. The candidate's primary residence must be within the greater Baltimore metropolitan area as are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. Bilingual - fluent in Spanish a big plus!

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 at post-acute places of service (Skilled Nursing Facility, Acute Rehab, Long Term Acute Care, Inpatient Hospice, and Home Health). Engages onsite and/or 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 appropriate referrals to other Care Management programs as appropriate for chronic, long term care coordination.