collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers
Performs care management activities within the scope of licensure for members with complex and chronic care needs
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions and extensions of stay, outpatient services, out of network services, and appropriateness of treatment setting and level of care
Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance
Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge
Conducts clinical assessment to develop goals that address individual needs in order to develop and implement a care plan
Monitors and evaluates effectiveness of the care management plan and modifies as necessary

Requires a HS diploma or equivalent and a minimum of 3 years of acute care clinical experience
Current, active valid unrestricted RN license in applicable state(s) required
Multi-state licensure is required if this individual is providing services in multiple states
Home health/discharge planning experience preferred
AS or BS in nursing preferred
Certification as a Case Manager is preferred
Critical care (ICU, Emergency Care, strong Medical Surgical background) preferred
For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice.
Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background.

Nurse Care Manager

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