Nurse Case Manager

Generali Global Assistance • Pembroke Pines, FL

6d • Hybrid

About The Position

Embark on a Journey That Makes a Difference. At Generali Global Assistance (GGA), every day is an opportunity to help people explore the world with confidence. We�re not just in the business of protection�we�re in the business of adventure and peace of mind. Whether it�s a backpacker trekking through the Andes, a family cruising the Mediterranean, or a solo traveler chasing the Northern Lights, we�re there to ensure their journey is safe and supported. From assisting with emergency medical claims to guiding customers through trip disruptions or ID theft, your work helps turn travel challenges into stories of resilience. Set Sail on a Career Path to Success. Our teams value curiosity and collaboration while priding ourselves on fostering a welcoming and inclusive atmosphere for our employees. Elevate your journey through our internal programs, including: Diversity, Equity, and Inclusion (DEI) Committee Career pathing and Individual Development Plans Internal training and intern opportunities Women in Business Mentorship Program Employee awards and recognition Education and professional development assistance program Passport to Perks Includes: Generous Employer contribution for health, dental, and vision insurance Paid Maternity and Paternity Leave Scholarship Program for Employee Dependents Company match on 401k Employee Assistance Program (EAP) Company paid short-term and long-term disability insurance Company paid life insurance Voluntary Pet Insurance Voluntary Legal Benefit Discounts on travel insurance Time off policies including vacation days, sick days, personal days, holidays and volunteer days (VTO)

Requirements

• High School Diploma or Equivalent (GED) required.
• Licensed Practical Nurse (LPN) or Registered Nurse (RN).
• Active license in the state of Florida.
• Keep license current and complete CEU's as mandated by the Board of Nursing in the state of Florida.
• At least two-year's experience in the field of Managed Care or related acute care areas; Medical/Surgical, OB/GYN, Pediatrics, Cardiology, Neurology, Nephrology, Orthopedics, Transplant and/or CCU/ICU.
• Maintains confidentiality of all pertinent client/member (patient) information.
• Strong organizational and time management skills required � with emphasis on prioritizing and performing multiple tasks in unison.
• Excellent communication skills (verbal and written).
• Exercises and displays the ability to interact effectively with physicians, providers, internal staff and insureds� as deemed necessary.

Nice To Haves

• Bilingual (any language)

Responsibilities

• Securing and reviewing clinical data to approve requests for admissions, procedures, and services that meet clinical review criteria.
• Ensuring coordination and delegation of care between all providers.
• Ensuring procedures/services are not duplicated and that services rendered fall within industry standards of care.
• Assessment of strengths and weaknesses.
• Implementation of a treatment plan.
• Coordination and availability of resources.
• Familiarity with the insured policy and its limitations.
• Communication and documentation with appropriate entities as per policies and procedures, adhering to HIPAA and/or GDPR compliance.
• Collecting client data and conducting emergent and non-emergent clinical assessments.
• Assisting in the referral of patients to the most appropriate provider specialty/facility within the Network.
• Monitoring and screening pre-authorization requests for second medical opinion referrals and/or diagnostic testing.
• Reviewing hospital admissions for medical necessity and assigning LOS in accordance with established criteria.
• Sending appropriate communication to providers, facilities, and/or clients.
• Referring cases that do not fall within pre-established criteria to the Supervisor for further evaluation and determination of admission approval, procedure, or services requested, or referring to Medical Director or peer reviewer.
• Assisting in assuring that verbal or written denial notices are distributed to the appropriate parties in a timely manner.
• Performing duties of the discharge planning nurse to contain LOS and assure the insured (member/patient) is receiving services within the 6 Rights: Care, Place, Time, Provider, Price, and Outcome.
• Assisting with the coordination (within all phases) of a repatriation/evacuation and working in accordance with individual Client Procedures as well as internal GMMI Work Instructions and/or Standard Operating Procedures.
• Reporting any change in insured's (member/patient) condition IMMEDIATELY to make any differing change in plans.
• Entering and maintaining all applicable information related to a case in GMMI�s operating software.
• Evaluating and reviewing treatment plans for consistency of care.
• Developing realistic treatment plans in conjunction with provider recommendations to meet client needs while providing the most appropriate and cost-effective method of delivering services.
• Evaluating and determining the availability of resources in conjunction with policy limits and coverage.
• Implementing cost management and delivering the most effective treatment plan.
• Maintaining current knowledge base regarding medical-surgical cases, utilization management, discharge planning, and continued care needs in relation to physician-approved criteria.
• Expanding knowledge base and becoming familiar with ICD-10 and how it improves cost containment efforts due to specificity.
• Responsible for updating the �Tracker� system and for the timely follow-up on each case monitored in the tracker.
• Functioning as a clinical resource to non-clinical staff.

Benefits

• Generous Employer contribution for health, dental, and vision insurance
• Paid Maternity and Paternity Leave
• Scholarship Program for Employee Dependents
• Company match on 401k
• Employee Assistance Program (EAP)
• Company paid short-term and long-term disability insurance
• Company paid life insurance
• Voluntary Pet Insurance
• Voluntary Legal Benefit
• Discounts on travel insurance
• Time off policies including vacation days, sick days, personal days, holidays and volunteer days (VTO)
• Diversity, Equity, and Inclusion (DEI) Committee
• Career pathing and Individual Development Plans
• Internal training and intern opportunities
• Women in Business Mentorship Program
• Employee awards and recognition
• Education and professional development assistance program
• Passport to Perks

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED