Case Management RN

    • Job Tracking ID: 512935-669526
    • Job Location: Meridian, ID
    • Job Level: Mid Career (2+ years)
    • Level of Education: BA/BS
    • Job Type: Full-Time/Regular
    • Date Updated: November 15, 2019
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
    • Salary Type:: Salary
    • Rate:: $60,000+ DOE
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Job Description:

The Case Management Registered Nurse position includes 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 internal guidelines/criteria to determine medical necessity and to coordinate care.

Key Result Areas

  • Assesses the member's current status, prognosis, future care needs, treatment plan and alternative treatment plans.
  • Work closely with providers to ensure appropriate utilization of services and effective case/cost management.
  • Establishes contact with member and develop, implement and evaluate individualized member care plan.
  • Acts as a liaison between referral source, physician and member and 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 specific clinical criteria guidelines, medical policies and plan benefit.
  • Provides authorization of services, or forwards requests to physician/Medical Adviser for determination.
  • Accesses and consults with peer clinical reviewers, Medical Adviser and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical 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.
  • Maintains concise documentation and confidentiality of records and information.
  • Attends on-site weekly company/team meetings and monthly staff meetings.
  • Performs all duties within the scope of license.
  • Performs other duties as assigned or needed.

Experience and Skills:

  • Current unrestricted RN license
  • Associates Degree in Nursing (Bachelor Degree is a plus).
  • Two (2) years of clinical or utilization review experience.
  • Certification in Case Management preferred.
  • Knowledge of UR/Case Management functions, self-funded insurance plans, networks and coding.
  • Strong interpersonal/communication (verbal and written) and the ability to work effectively with a diverse patient population.
  • Ability to work independently and with a team.
  • Ability to maintain confidentiality, work efficiently in fast paced environment, prioritize tasks, and meet tight deadlines.
  • Completes all projects in a timely and accurate manner.
  • Experience using a video-conferencing system.
  • Types 45 wpm, 10-key and computer knowledge.
  • Able to demonstrate excellent attendance and punctuality.
  • Excellent customer service attitude and professionalism.
  • Demonstrate Accuracy, Customer Service, Timely Turn-Around (ACT).
  • Proficiency using Microsoft Office (Word, Excel, Outlook, etc.).
  • Possess a high degree of integrity and discretion, as well as the ability to adhere to both company policies and best practices.
  • Ensure compliance with security practices and procedures, including HIPAA and HITRUST standards.
  • 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.
  • Protect and enhance the Core Purpose and the Core Values of AmeriBen.

AmeriBen is an Equal Opportunity/Affirmative Action 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.

If you are unable to use our online application process due to a disability, please contact the Human Resources Department at humanresources@ameriben.com.