The unseen heroes of health insurance – case management nurses

As a case manager for Blue Cross and Blue Shield of Kansas, Jennifer Powers works directly with many of our members who have chronic, severe or catastrophic illnesses. She advocates for them, collaborates with their providers, advises them about cost-effective treatments, and helps them understand how to get the best value from their healthcare.

At its core, case management helps our members and their families who are facing complex healthcare decisions. Being a case manager is different than the hands-on care Jennifer used to provide during her 10 years as a registered nurse. But, the behind-the-scenes research she does, and the follow-up care that results, can have a profound impact on the lives of the people she works with.

For example, right now, Jennifer is working with about 30 – 40 members. Some of them are at home; others are at the hospital or another care facility. Every phone call she makes is important, although some are simpler than others. For example, she may call a member after knee surgery to check on how they’re feeling, assess their condition or answer questions about their medications. Or, she may help someone who is transferring to a new level of care, for example, from hospital to home care. She also works with members who are in crisis mode. Maybe they have a high-risk pregnancy, suffered a stroke or a heart attack, were in a car accident or have a spinal cord injury. For them, the work is more complex. Jennifer does all she can to help members navigate care during a time of great difficulty.

Jennifer’s story

“So you can understand what I do, I’ll share a simple story about a 12-year-old boy I worked with named Harper. When he was just 5 years old, Harper was diagnosed with Chron’s disease. For three years, he traveled hours for the infusion therapy he needed to decrease inflammation and keep the disease in remission. As he grew older, though, these day-long appointments took a toll on Harper and his family. He missed school and sports practices. He also had to answer questions from classmates and teachers about why he was absent so often. When Harper was referred to Jennifer, she called his mother and listened to her story. Jennifer also talked to the physician, who wasn’t willing to budge on the location of Harper’s therapy. So, she did some research and talked with physicians at the local hospital near Harper’s home. After some coordination, they agreed to do the therapy, and soon those day-long trips were a thing of the past. The local hospital was also able to offer more convenient appointment times, so Harper didn’t have to miss school or the activities he enjoyed. Ultimately, all of this effort resulted in cost savings, too.”

In case management, our nurses wear all kinds of hats, yet much of their work is unseen. For the people they work with, case managers are the main point of contact at Blue Cross and Blue Shield of Kansas. So, when possible, they strive to develop a personal relationship. They work hard to close gaps in care by directing members toward therapies that are appropriate for their disease or condition. They break down complex medical conditions to be more easily understood. They help members navigate through options such as Medicare or Medicaid, nursing facilities or palliative care. They direct them to resources such as Meals on Wheels, or help them locate transportation so they can get to their appointments. Every person is different and requires a unique level of care.

Even when a healthcare service isn’t covered under a member’s contract, our case managers do all they can to help provide other options. They talk with the member’s healthcare providers to get the full picture. They see if there are exceptions that can be made. They do research about how other Blues Plans handle complex cases. They exhaust all the possibilities. Case managers really strive to show the member that Blue Cross and Blue Shield of Kansas is more than a health insurance company. They want them to know that we care. Because that’s what case management is all about.

As a case manager, Jennifer knows that her work has a direct and deep impact on our members. It improves their health and safety. It provides them with a better experience. It drives them toward savings. And it provides a meaningful, valuable service when they need it most.

Our dedicated case managers work closely with the member, the member’s families and the member’s health care team to coordinate quality care, in the right place at the right time. Learn more about case management and hear Jennifer’s story in her own words.

Leave a Reply