About The Position
Responsible for case management services within the scope of licensure; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum Performs telephonic clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services, and long-term services Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost-effective and efficient utilization of health benefits; conducts gap in care management for quality programs Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangement permissible Interfaces with Medical Directors, Physician Advisors, and/or Inter-Disciplinary Teams on care management treatment plans Presents cases at case conferences for multidisciplinary focus. Ensures compliance with regulatory, accrediting, and company policies and procedures May assist in problem-solving with provider, claims, or service issues.
Requirements
- Registered Nurse (RN) License (Compact or Virginia) REQUIRED
- 3 years of Case Management RN experience REQUIRED
Nice To Haves
- Complex Case Integrated Commercial Managed Care and discharge planning preferred.
- Experience in the ICU/ED, Behavioral Health, and Oncology are helpful.
- Experience with JIVA and Epic experience preferred.
- Proficient with NCQA guidelines
Responsibilities
- Responsible for case management services within the scope of licensure
- Develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum
- Performs telephonic clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services, and long-term services
- Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team
- Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost-effective and efficient utilization of health benefits
- Conducts gap in care management for quality programs
- Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangement permissible
- Interfaces with Medical Directors, Physician Advisors, and/or Inter-Disciplinary Teams on care management treatment plans
- Presents cases at case conferences for multidisciplinary focus.
- Ensures compliance with regulatory, accrediting, and company policies and procedures
- May assist in problem-solving with provider, claims, or service issues.
Benefits
- Medical, Dental, Vision plans
- Adoption, Fertility and Surrogacy Reimbursement up to $10,000
- Paid Time Off and Sick Leave
- Paid Parental & Family Caregiver Leave
- Emergency Backup Care
- Long-Term, Short-Term Disability, and Critical Illness plans
- Life Insurance
- 401k/403B with Employer Match
- Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
- Student Debt Pay Down – $10,000
- Reimbursement for certifications and free access to complete CEUs and professional development
- Pet Insurance
- Legal Resources Plan
- Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
