Nurse Case Mgr II

Nurse Case Mgr II

Requirements

• Requires BA/BS in a health related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current, unrestricted RN license in applicable state(s) required.
• Multi-state licensure is required if this individual is providing services in multiple states.

Responsibilities

• 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.
• Assists with development of utilization/care management policies and procedures.

Preferred Qualifications

• Certification as a Case Manager is preferred.
• BS in a health or human services related field preferred.
• Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Knowledge of the medical management process and the ability to interpret and apply member contracts, member benefits, and managed care products are strongly preferred.
• Prior managed care experience is strongly preferred.