Nurse Case Manager Lead
About The Position
The Telephonic Nurse Case Manager Lead is responsible for care management, within the scope of licensure, for members with complex and chronic care needs. The role assesses, develops, implements, coordinates, monitors, and evaluates care plans to optimize member health care across the care continuum and ensure access to services appropriate to members’ health needs. Duties are performed telephonically or on-site, including at hospitals for discharge planning. This role supports care management operations and staff by assisting with daily workflow and coaching, serving as a first-line contact for conflict resolution, contributing to policies and procedures, conducting audits and process evaluations, and developing training materials. It may also involve developing focused expertise in a disease process or traumatic injury and serving as a preceptor for new care management staff. The position is primarily virtual, with required in-person training sessions. Candidates generally must live within a reasonable commuting distance of a posting location, unless a legally required accommodation applies. The stated schedule is Monday through Friday, 11:30 a.m. to 8:00 p.m. Eastern Time.
Requirements
- BA/BS in a health-related field and five years of clinical experience, or an equivalent combination of education and experience.
- Current, unrestricted RN license in applicable state(s).
- Case manager certification required within three years of starting in the role.
- Managed care experience is necessary.
Nice To Haves
- Certification as a Case Manager is preferred.
- A BS in a health- or human-services-related field is preferred.
- Case management experience is a plus.
Responsibilities
- Conduct assessments to identify members’ individual needs and develop care management plans addressing goals and objectives identified during assessment.
- Implement care plans by facilitating authorizations and referrals within the benefits structure or through extra-contractual arrangements, as appropriate.
- Coordinate internal and external resources to meet identified needs.
- Monitor and evaluate care plan effectiveness and modify plans as necessary.
- Interface with Medical Directors and Physician Advisors to develop care management treatment plans.
- Negotiate reimbursement rates, as applicable.
- Help resolve provider, claims, or service issues.
- Assist with development of utilization and care management policies and procedures.
- Chair and schedule meetings, present cases at Grand Rounds and Care Conferences, and participate in interdepartmental or cross-brand workgroups.
- Develop focused expertise in a specific disease process or traumatic injury, as needed, and serve as a preceptor for new care management staff.
- Participate in audit activities and assist the supervisor with day-to-day operations, including monitoring and prioritizing workflow, providing constructive coaching and feedback, and developing corrective action plans at the manager’s direction.
- Serve as the first-line contact for conflict resolution.
- Develop training materials, complete quality audits, perform process evaluations, and test and monitor system or process enhancements.
- Perform care management duties telephonically or on-site, including hospital discharge planning.
Benefits
- $3,000 sign-on bonus.
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase plan.
- 401(k) contribution and match.
- Merit increases.
- Paid holidays.
- Paid Time Off.
- Incentive bonus programs, unless covered by a collective bargaining agreement.
- Medical insurance.
- Dental insurance.
- Vision insurance.
- Short- and long-term disability benefits.
- Life insurance.
- Wellness programs.
- Financial education resources.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
