Primary Nurse Case Manager
3 days ago
This position is responsible for performing all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM) and is a single source of contact for members, health care personnel and all other entities involved in managing care.
Key Responsibilities- Perform concurrent review, discharge planning and care coordination
- Identify alternate treatment programs and consult with physicians, providers, members, and other resources to evaluate options and services required to meet an individual's health needs
- Promote quality and cost-effective outcomes and serve as liaison to physicians and members
- Provide education and local resource information and encourage member self-education
- Assess members for wellness education and disease management and introduce members to our website tools
- Registered Nurse (RN) with current, valid, unrestricted license in state of operations
- 2 years clinical practice experience of direct clinical care to the customer
- 1 year experience in Condition Management or Case Management in a health insurance, managed care, physician office or hospital setting
- PC proficiency to include Word, Excel, Lotus Notes and database experience
- Clear and concise verbal and written communication skills
- Knowledge of UM/CM/DM activities and standardized criteria set
- Familiarity of ancillary services including HHC, SNF, Hospice, etc
- Experience in managing complex or catastrophic health cases
- Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
- Working toward or completion of CCM/CCP/CDE certification or Advanced degree
- Knowledge of Milliman Guidelines or similar clinical guidelines
- Knowledge of medical management policies and procedures
This is a work from home position in Houston, TX. You must live in or near Houston, TX for this role. Will visit members in Houston based hospitals. This is 100% case management.
HCSC is an Equal Opportunity Employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued.
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