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Case Manager RN

2 months ago

Largo, United States Diagnostic Clinic Medical Group Full time

Get To Know Us

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.

What is your impact?

The RN Case Manager primary responsibility is to create, implement, and monitor treatment plans to assist patients/members in meeting their healthcare goals. You would use knowledge of healthcare and social services to assess needs and provide interdisciplinary care options in treatment planning for the member. This would include understanding the member's healthcare benefits and healthcare best practices needed for effective treatment planning.

What Will You Be Doing:

The essential functions listed represent the major duties of this role, additional duties may be assigned.

  • Case Management process includes assessing the member's health status and care coordination needs. Can include inpatient review and discharge planning, as well as possible outpatient management. (10%)
  • Contact with patient, family, physicians, additional health care providers, and community resources. Contact with provider business offices and with the employer/client may also be required. (10%)
  • Identification of alternative treatment plans, which would have to be approved by all parties. These alternative care plans will be based on quality care within cost containment guidelines, allowing available claims dollars to be used in the most judicious manner possible. (10%)
  • Assessment of the clinical status and resultant sequela to coordinate the most appropriate service to meet the individual's health care needs. The Case Manager will then monitor the health status and the impact of the treatment plan for each client. The Case Manager will be responsible for altering the care plan as deemed appropriate by the dynamic, ever-changing client needs. (10%)
  • Identification of services, resources, providers, and facilities that could best serve members in a timely and cost-effective manner, to promote optimum value for the client and reimbursement source. (10%)
  • Development and implementation of Case Management goals, both short and long term, with documented care plans. (10%)
  • Utilize technology/resources to evaluate the cost-effectiveness of the elected treatment plan, pre-implementation and post-implementation. This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans. (10%)
  • Accurate and timely reporting as deemed appropriate by each client member. (10%)
  • Medical record review to determine medical necessity of requested services. (10%)
  • Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions. (10%)

What You Must Have:

  • 5+ years related work experience with a professional background in clinical nursing and patient assessment.
  • Related Bachelor's degree or additional related equivalent work experience
  • Graduate of an accredited school of nursing
  • RN - Registered Nurse - Compact State Licensure in good standing
  • Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
  • Computer skills.
  • Ability to collaborate with cross-operational areas within the organization.
  • Good verbal and written communication skills.
  • Ability to work as a team member, effectively and collaboratively, with non-clinical teammates.
  • Adherence to ethical, legal and accreditation/regulatory standards.
  • Maintaining client's privacy, confidentiality and safety as well as acting as an advocate for the covered member.
  • Ability to travel is approximately 10% of the time is required.

What We Prefer:

  • Prior experience in utilization management or case management preferred, preferably within the managed care environment
  • Intensive care or higher-acuity patient experience preferred.
  • Proficiency in maintaining good rapport with other staff members, physicians, health care facilities, clients, and providers.
  • Knowledge of managed care in a self-funded employer population is preferred.
  • Ability to identify problems such as underutilization or overutilization of services
  • Ability to promote and maintain quality care through analysis

What We Can Offer YOU

To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:

  • Medical, dental, vision, life and global travel health insurance
  • Income protection benefits: life insurance, Short- and long-term disability programs
  • Leave programs to support personal circumstances
  • Retirement Savings Plan includes employer contribution and employer match
  • Paid time off, volunteer time off, and 11 holidays
  • Additional voluntary benefits available and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ.

General Physical Demands:

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.