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Primary Nurse Case Manager
2 months 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, healthcare personnel and all other entities involved in managing care.
Key Responsibilities- Concurrent review, discharge planning and care coordination
- Identifies alternate treatment programs
- Consults with physicians, providers, members, and other resources to evaluate options and services required to meet an individual's health needs
- Promotes quality and cost-effective outcomes
- Serves as liaison to physicians and members
- 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 role in Texas. You must live in Texas for this position. Relocation assistance will not be provided for this position. Sponsorship will not be provided for this position.
