Nurse Case Manager

GMMI•Pembroke Pines, FL

6d•Hybrid

About The Position

The Nurse Case Manager is a licensed practical nurse or registered nurse responsible for obtaining and reviewing clinical information to assess and approve requests for admissions, procedures, and services that meet established clinical review criteria. The role coordinates care among providers, helps prevent duplicate services, and ensures that care follows industry standards. The case manager assesses patient needs, develops and coordinates treatment plans and resources, understands policy coverage and limitations, and communicates and documents case information in accordance with applicable procedures and HIPAA and/or GDPR requirements. Decisions are not financially incentivized based on underutilization, adverse determinations, or denials; case managers do not issue non-certifications. This is a hybrid role based in the Pembroke Pines, Florida office, with employees working onsite two to three days per week and from home two to three days per week.

Requirements

High school diploma or equivalent (GED).
Licensed health professional: LPN or RN.
Active nursing license in the state of Florida; maintain the license and complete continuing education units as required by the Florida Board of Nursing.
At least two years of experience in managed care or related acute-care areas, such as medical/surgical, OB/GYN, pediatrics, cardiology, neurology, nephrology, orthopedics, transplant, or CCU/ICU.
Strong organizational and time-management skills, including prioritizing and performing multiple tasks concurrently.
Excellent verbal and written communication skills.
Ability to interact effectively with physicians, providers, internal staff, and insureds as necessary.

Nice To Haves

Bilingual in any language.

Responsibilities

Collect client data and conduct emergent and non-emergent clinical assessments.
Assist with referrals to the most appropriate in-network provider specialty or facility.
Monitor and screen pre-authorization requests for second medical opinions and/or diagnostic testing.
Review hospital admissions for medical necessity and assign length of stay in accordance with established criteria.
Communicate with providers, facilities, and clients as appropriate.
Refer cases outside pre-established criteria to a supervisor for evaluation and determination, or to a medical director or peer reviewer.
Help ensure verbal or written denial notices are distributed to appropriate parties in a timely manner once a denial has been determined.
Perform discharge-planning duties to manage length of stay and help ensure members receive services consistent with the six rights: care, place, time, provider, price, and outcome.
Coordinate repatriation and evacuation through all phases, following client procedures and internal work instructions and standard operating procedures.
Immediately report changes in a member or patient’s condition so plans can be adjusted.
Enter and maintain case information in the company’s operating software.
Evaluate treatment plans for consistency of care and develop realistic plans with provider recommendations that meet client needs using appropriate, cost-effective services.
Evaluate resource availability in conjunction with policy limits and coverage, and implement cost-management measures.
Maintain knowledge of medical-surgical cases, utilization management, discharge planning, and continued-care needs in relation to physician-approved criteria; develop familiarity with ICD-10 and its role in cost containment.
Update the Tracker system and follow up promptly on monitored cases.
Serve as a clinical resource to non-clinical staff.
Maintain the confidentiality of client/member or patient information.

Benefits

Employer contributions toward health, dental, and vision insurance.
Paid maternity and paternity leave.
Scholarship program for employee dependents.
Company 401(k) match.
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.