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
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 quickly is preferred
Ability to manage, review and respond to emails/instant messages in a timely fashion is preferred

Nurse Case Manager

Key skills