Overview

This position revolves around the personalized, timely, comprehensive, and cost-effective approach to member health related services. The Nurse Case Manager (NCM) collaborates with a variety of people and entities including, but not limited to providers, pharmacies, vendors, care facilities, hospitals, and other community services. The NCM uses judgement in selecting appropriate guidelines and in applying general policies and procedures. The NCM performs prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care. May establish care plans and coordinate care through the health care continuum including member outreach assessments.

The NCM provides a variety of nursing services, predominately by phone, to address acute and chronic needs of our health plan members.

Job Duties

• Analyze, research, respond to, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory standards

• Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols

• Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities

• Work with the Medical Director to determine medical necessity and coverage indications through the prior authorization process 

• Maintain effective written and verbal communication with the members and associated professionals

• Document all case management and care coordination activities within the designated software

• Demonstrate an ongoing understanding of Medicare/Customer Benefits

• Assists with issues that may arise due to quality of care and/or adverse risk review

• Complies with customer’s internal policies and procedures 

• Other duties as assigned

Professional Competencies

• Outstanding customer service and interpersonal skills

• Excellent written and oral communication

• Provides critical attention to detail for accuracy and timeliness

• Works autonomously and effectively sets priorities

• Manages multiple tasks and remains flexible in a dynamic work environment

• Exercises sound clinical judgement, independent analysis, critical thinking skills and knowledge of health conditions to determine best outcomes for members

• Technically comfortable working within multiple computer systems 

• Demonstrates clinical knowledge and experience relative to patient care and healthcare delivery processes

• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management

Preferred Experience

• Relevant clinical experience which may include acute patient care, discharge planning, case management, utilization review, etc.

• Certification as a case manager

• One (1) year of health insurance plan experience or managed care environment preferred

Preferred Education and Training: 

• Graduate of an accredited nursing program

Required Licensing or Certification: 

• Current unencumbered RN or LPN license

Role Details

• Job Type: Contract

• Reports to Director of Medical Management

• Standard business hours, Monday through Friday

• Evenings, weekends or holiday coverage, as needed

• Work Location: Remote