Case Manager, Registered Nurse

Role Overview

• working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients
• Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory standards while assessing benefits and/or member’s needs
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues
• Consults with supervisor and others in overcoming barriers in meeting goals and objectives
• presents cases at case conferences for multidisciplinary focus to benefit overall claim management
• Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives
• Utilizes case management processes in compliance with regulatory and company policies and procedures
• Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations
• Identifies and escalates member’s needs appropriately following set guidelines and protocols
• Need to actively reach out to members to collaborate/guide their care
• Perform medical necessity reviews.

Requirements

• 5+ years’ experience as a Registered Nurse with at least 1 year of experience in a hospital setting
• A RN who resides in a compact state is required to have an active multistate license through the Nurse Licensure Compact (NLC)
• 1+ years’ experience documenting electronically using a keyboard
• 1+ years’ current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics experience.
• 1+ years’ Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care.
• 1+ years' experience in Utilization Review
• CCM and/or other URAC recognized accreditation preferred.
• 1+ years’ experience with MCG, NCCN and/or Lexicomp
• Bilingual in Spanish preferred.

Benefits

• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility