This job provides education to members calling into the Blues on Call (BOC) line. Generally, these members are requesting information related to specific disease questions, symptom management and/or general health and wellness. The incumbent provides education on the Blues on Call service, which can assist with acute symptomology and general health information. Uses clinical and motivational interviewing skills to assess members’ needs and establish mutually agreeable short and long term goals. Supports members in developing improved knowledge to enhance self-management skills and adopting positive behavior changes. Works with the member to identify and address barriers to adherence to standards of evidence-based medicine to optimize outcomes for these conditions. Identifies whether members need assistance in coordinating care and navigating the healthcare system and proactively incorporates lifestyle improvement and prevention opportunities into member interventions and identifies and closes gaps in care.
- Serve as a frontline educator for members who call into the BOC line with specific medical questions, symptoms or concerns related to their health and wellness. Across the continuum of services, the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making to optimize their clinical outcomes.
- Conduct outreach to members who over utilize the ER and/or who utilize the ER for avoidable diagnoses.
- Direct membership accordingly, to: lower level cost-of-care sites when appropriate
- Identify or assist with establishing contact with a Primary Care Physician for coordination of care.
- Locate and provide information on Urgent Care Centers in their geographical area.
- Educate on the Blues On Call service which can assist with acute symptomology and general health information.
- Conduct clinical assessments telephonically with approved assessment tools and protocols to address the condition specific health and wellness needs of members. Clinical and motivational interviewing skills are utilized with the goal of effecting members’ self-management and positive behavior changes to achieve condition related goals.
- Identify on-line, telephonic and clinical resources that can assist the member to achieve and maintain their personal health goals and assists the member to access those services.
- Identify when members need a more advanced level of intervention or have reached goals and takes appropriate action.
- Proactively incorporate lifestyle improvement and prevention opportunities into member interactions, coaching and goals; incorporate and assists members in closing any gaps in care.
- Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
- Account for progress of members served and is accountable for results.
- Collaborate with a multi-disciplinary team accordingly and refer to: case managers for members who have complex health needs, disease managers to assist with chronic condition management, social workers to assist with financial needs and community resources, pharmacy for medication needs and behavior health specialists for mental health needs.
- Other duties as assigned or requested.
- 5 - 7 years of any combination of clinical, case management and/or disease/condition management experience
- Registered Nurse
- High School Diploma or GED
- Bachelor's Degree in Nursing
- Advanced training in disease management
- Advanced training and experience in cognitive behavior therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT)
- Experience working with the healthcare needs of diverse populations and understanding of the importance of cultural competency in addressing targeted populations
- Ability to communicate effectively in more than one language
- Understanding of the role of lifestyle in disease processes
- Call center experience
- Interpersonal and communication skills
- Broad knowledge of disease processes
- Understanding of healthcare costs and the broader healthcare service delivery system
- Proficient computer skills, including MS Office products
- Demonstrated ability to handle multiple priorities in a fast paced environment
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