Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals.
Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions.
Participates in direct intervention/patient education with members and providers regarding health care delivery system.
May identify, initiate, and participate in on-site reviews.
Serves as member advocate through continued communication and education.
Promotes enrollment in care management programs and/or health and disease management programs.
Provides appropriate communications regarding requested services to both health care providers and members.
Performs medical or behavioral review/authorization process.
Ensures coverage for appropriate services within benefit and medical necessity guidelines.
Utilizes allocated resources to back up review determinations.
Identifies and makes referrals to appropriate staff.

An active, unrestricted RN license from the United States and in the state of hire OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
Associate Degree
Nursing, OR, Graduate of Accredited School of Nursing
Four years recent clinical in defined specialty area
Working knowledge of word processing software
Knowledge of quality improvement processes and demonstrated ability with these activities
Knowledge of contract language and application
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated proficiency in spelling, punctuation, and grammar skills
Ability to persuade, negotiate, or influence others
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Microsoft Office proficiency
URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager

RN Navigator Case Manager – MCC II

Key skills