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; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted RN license in the state of Virginia is required.
Multi-state licensure is required if this individual is providing services in multiple states.
Certification as a Case Manager is preferred.
MCO case management experience preferred.
Experience in hospice, home health, critical care within a hospital setting, pediatrics or adult hospital care is preferred.

Nurse Case Manager I

Key skills