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.
Assists with development of utilization/care management policies and procedures.

Requires BA/BS in a health related field and minimum of 5 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.
Certification as a Case Manager preferred.
BS in a health related field is preferred.
Ability to talk and type at the same time preferred.
Demonstrate critical thinking skills when interacting with members preferred.
Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly preferred.
Ability to manage, review and respond to emails/instant messages in a timely fashion preferred.
Minimum 2 years’ experience in acute care setting preferred.
Minimum 2 years’ "telephonic" Case Management experience with a Managed Care Company preferred.
Managed Care experience preferred.

Nurse Case Manager II

Key skills