Case Management Registered Nurse

    • Job Tracking ID: 512935-830749
    • Job Location: Remote, USA
    • Job Level: Mid Career (2+ years)
    • Level of Education: 2 year degree
    • Job Type: Full-Time/Regular
    • Date Updated: September 27, 2022
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
    • Salary Type:: Salary
    • Rate:: $62,000+ DOE
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Job Description:

 

Job Purpose

The Case Management Registered Nurse provides planning, coordinating, implementing, monitoring, and evaluating the medical services required to meet the complex health needs of our members, while cost-effectively achieving desired clinical outcomes and enhancing the quality of medical care. It is characterized by advocacy, communication, and resource management, while promoting quality and cost-effective interventions and outcomes. The case manager’s role includes contact with the participant and/or provider(s), coordination of services within the health care arena, and utilization of criteria guidelines/medical policies and plan language to determine medical necessity and to coordinate care.

 

Key Functions

  • Assesses the member's status, prognosis, future care needs, treatment plan and alternative treatment plan options.
  • Works closely with providers to ensure appropriate utilization of services and effective case/cost management.
  • Establishes contact with member and develops, implements, and evaluates individualized member care plan.
  • Acts as a liaison between referral source, physician, and member to coordinate appropriate cost- effective recommendations.
  • Conducts post hospitalization calls.
  • Determines medical necessity and appropriateness of requested inpatient and outpatient services through review of clinical information and application of the appropriate clinical criteria guidelines/medical policies and plan language. Provides authorization of services, or forwards requests to Medical Director for determination.
  • Consults with Medical Director(s) to ensure medically appropriate, quality, cost effective care throughout the case management process.
  • Facilitates communication with health care providers involved with the care of the member to obtain complete and accurate information, to coordinate care, to advise of determinations, and to educate regarding medical management processes/member’s needs.
  • Communicates with providers and other departments to facilitate care, referrals, transitions of care, and discharge planning.
  • Identifies solutions to non-standard requests and problems.
  • Identifies members for referral opportunities to integrate with other services (i.e., Disease Management, Maternal Health etc.).
  • Maintains appropriate documentation and records cost management.
  • Attends on-site weekly company/team meetings and monthly staff meetings.
  • Ensure compliance with security practices and procedures, including HIPAA and HITRUST standards.
  • Protects and enhances the daily culture and environment of AmeriBen. Fosters, supports, and demonstrates the company Core Purpose and Core Values.
  • Performs all duties within the scope of licensure.
  • Performs other duties as assigned or needed.

 

Experience and Skills:

 

 

Minimum Qualifications & Education

  • Current unrestricted RN license
  • Associates Degree in Nursing (Bachelor Degree is a plus).
  • Minimum of two years of clinical or utilization review experience.
  • Diverse clinical experience preferred
  • Knowledge of medical/health insurance terminology, ICD-10/ICD-11, HIPAA and DOL regulations.
  • Proficiency with Microsoft Office products (Word, Excel, Outlook, etc.).
  • Strong verbal and written communication skills.
  • Experience using video conferencing.
  • Excellent customer service attitude, accuracy, and professionalism.
  • Ability to efficiently and effectively perform the Key Result Areas with or without a reasonable accommodation without posing a direct safety threat to others or self.

 

Preferred Qualifications

  • Experience in Utilization or Case Management or Certification in Case Management preferred.
  • Understanding of Case Management functions, self-funded insurance plans and PPO networks.
  • Types 45 wpm, 10-key and computer knowledge.
  • Strong interpersonal skills and the ability to work effectively with a diverse patient population.
  • Interest in future leadership development opportunities preferred.
  • Effective communication, both verbally and in writing.

 

AmeriBen is an Equal Opportunity Employer committed to creating an environment of diversity and inclusion for equal employment and advancement opportunities to all employees and applicants for employment. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, national origin, sex, sexual orientation, gender identity and/or expression, genetic information, disability, veteran or military status, or any other category protected by federal, state and/or local law.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. If you are unable to use our online application process due to a disability, please contact the Human Resources Department at humanresources@ameriben.com or call 208-488-7654.