RN Medical Case Manager

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.

Experience

• 3 years - Clinical experience required
• 5 years - Experience in the health care industry
• For Select Community & Katie Beckett: 2 years experience in IDD for Select Community is required

Skills\Certifications

• Excellent oral and written communication skills
• PC Skills required (Basic Microsoft Office and E-Mail)

Number of Openings Available: 1

Worker Type: Employee

Company: VSHP Volunteer State Health Plan, Inc