Case Management RN

WPS Health Solutions New • Madison, WI

20d • $75,000 - $100,000 • Remote

About The Position

Our Case Management RN (Registered Nurse) coordinates care and services of select member populations with complex health care needs across continuum of care. The primary focus of the role is the development and continuous monitoring of a member-centric plan of care that promotes effective utilization of health care services while maximizing quality and cost-efficiency of these services for members. Our Case Management RN routinely educates members and family members on plans of care while serving as a liaison between the members, their families and health care providers.

Requirements

• Registered Nurse (RN) with current licensure in the state of Wisconsin OR current Compact License.
• 4 or more years of experience as a Registered Nurse in varied clinical settings (i.e., hospital, clinic, home care, skilled nursing facility, etc.).
• 2 or more years of case management experience.
• Demonstrated experience managing and coordinating care effectively for case managed members.
• Strong knowledge of clinical care management processes, care coordination, and case management principles.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Strong diverse experience and expertise that includes: The ability to work independently, manage a case load, and prioritization.
• Excellent analytical, critical thinking, problem-solving skills and decision-making skills.
• Excellent communication and interpersonal skills to work with members, providers, and teams
• Proficiency in Microsoft Office and healthcare software and systems.
• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net )

Nice To Haves

• Bachelor’s degree in nursing (BSN).
• Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement) plans preferred.
• Certified Case Manager (CCM) preferred.
• Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software.

Responsibilities

• Developed and implemented individualized care plans, short term and long-term goals for case managed members.
• Reviewing and providing prior authorization decisions for selective high-cost services including but not limited to transplant, dialysis, CAR-T/gene therapy.
• Interfaced with utilization management for select authorization services.
• Serving as an advocate for the member’s needs and preferences and can identify and address barriers to care.
• Coordinate medical services and resources, facilitate transitions of care between settings, and assist with site of care redirections as needed.
• Help members manage their conditions and address unique issues during their care transitions.
• Educate members and caregivers on appropriate and available community resources, how to prepare for physician visits, and how to overcome barriers and achieve medication compliance.
• Assess motivational or psychosocial issues for case managed members and facilitate case management members to achieve wellness and autonomy.
• Identify legal or liability issues and refer potential ethical or risk management issues to the appropriate department for review and resolution.
• Document all care management activities and analyze / report care management activities that could include, identification of high risk, high cost and high utilization cases.
• Maintain accurate, up-to-date case notes, care plans, and other documentation in compliance with health plan guidelines, state, and federal regulations.
• Work cross functionally to support other departmental efforts to ensure overall efficiency, quality, productivity and compliance with all departmental and regulatory standards.

Benefits

• Remote work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary ( 100% vested immediately )
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Professional and Leadership Development Programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed