Performs care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum.
Performs duties telephonically for discharge planning.
Ensures member access to services appropriate to their health needs.
Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
Coordinates internal and external resources to meet identified needs.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Negotiates rates of reimbursement, as applicable.
Assists in problem solving with providers, claims or service issues

Requires BA/BS in a health related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted RN license in applicable state(s) required.
Multi-state licensure is required if this individual is providing services in multiple states.
Case Management experience is preferred.
Minimum 2 years’ experience in acute care setting is preferred.
Managed Care experience is preferred.
Ability to talk and type at the same time is preferred.
Demonstrate critical thinking skills when interacting with members is preferred.
Experience with Microsoft Office and/or ability to learn new computer programs/systems/software quickly is preferred.
Ability to manage, review and respond to emails/instant messages in a timely fashion is preferred.

Nurse Case Manager I

Key skills