RN Case Management Coordinator – Maternity, NICU

Role Overview

• Provides active care 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, utilization on networks and benefit plans
• 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
• Participates in data collection/input into system for clinical information flow and proper claims adjudication
• Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies
• Maintains current knowledge of contracts and network status of all service providers

Requirements

• Associates in a job-related field
• 4 years recent clinical experience in defined specialty area
• Working knowledge of word processing software
• Knowledge of quality improvement processes
• Knowledge of contract language and application
• Ability to work independently, prioritize effectively, and make sound decisions
• Good judgment skills
• Demonstrated customer service, organizational, and presentation skills
• Demonstrated proficiency in spelling, punctuation, and grammar skills
• Demonstrated oral and written communication skills
• Ability to persuade, negotiate, or influence others
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion
• 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) OR active, unrestricted licensure as counselor, or psychologist from the United States and in the state of hire (in Div. 75 only)

Benefits

• Subsidized health plans
• Dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more