Primary Nurse Case Admin 1 - Work From Home

Health Care Service Corporation•El Paso, TX

3d•$61,500 - $136,100•Remote

About The Position

This position is responsible for performing all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM) and is a single source of contact for members, health care personnel and all other entities involved in managing care. The Primary Nurse Coordinator performs concurrent review, discharge planning and care coordination; identifies alternate treatment programs; consults with physicians, providers, members, and other resources to evaluate options and services required to meet an individual’s health needs; promotes quality and cost effective outcomes; and serves as liaison to physicians and members. Other functions also include episodic case management, determining member assignment of treatment, and pre-admission/post-discharge counseling for an acute condition. Establish relationship with the member through the immediate post discharge follow-up period or until all short term care needs are met. Provide education/local resource information and encourage member (self) education. Functioning in a clinical care advisory role, the Primary Nurse Coordinator assesses members for wellness education and disease management, introduces members to our website tools, educates members regarding wellness and specific conditions, and facilitates the coordination of care for identified members.

Requirements

Registered Nurse (RN) with current, valid, unrestricted license in state of operations
2 years clinical practice experience of direct clinical care to the customer
1 year experience in Condition Management or Case Management in a health insurance, managed care, physician office or hospital setting.
PC proficiency to include Word, Excel, Lotus Notes and database experience
Clear and concise verbal and written communication skills
Knowledge of UM/CM/DM activities and standardized criteria set
Familiarity of ancillary services including HHC, SNF, Hospice, etc
Verbal and written communication skills; analytical skills; sound clinical judgment
Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management. Multi-state license fees will be provided by HCSC.
Must have an active and unrestricted Nursing license (in Texas) or an active and unrestricted Compact Nursing license.

Nice To Haves

Experience in managing complex or catastrophic health cases
Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
Working toward or completion of CCM/CCP/CDE certification or Advanced degree
Knowledge of Milliman Guidelines or similar clinical guidelines
Knowledge of medical management policies and procedures

Responsibilities

Performing all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM)
Serving as a single source of contact for members, health care personnel and all other entities involved in managing care
Performing concurrent review, discharge planning and care coordination
Identifying alternate treatment programs
Consulting with physicians, providers, members, and other resources to evaluate options and services required to meet an individual’s health needs
Promoting quality and cost effective outcomes
Serving as liaison to physicians and members
Episodic case management
Determining member assignment of treatment
Pre-admission/post-discharge counseling for an acute condition
Establishing relationship with the member through the immediate post discharge follow-up period or until all short term care needs are met
Providing education/local resource information and encouraging member (self) education
Assessing members for wellness education and disease management
Introducing members to website tools
Educating members regarding wellness and specific conditions
Facilitating the coordination of care for identified members