Primary Nurse Case Administration I - Utilization Management (Health Advocacy Solutions)

Health Care Service Corporation • Richardson, TX

279d • $60,300 - $133,400 • 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, Outlook and database experience.
• Clear and concise verbal and written communication skills.
• Knowledge of UM/CM/DM activities and standardized criteria set.
• Familiarity with ancillary services including HHC, SNF, Hospice, etc.
• Strong analytical skills and sound clinical judgment.
• Incumbents with nursing licenses in positions requiring multi-state licenses must obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states.

Nice To Haves

• Registered Nurse COMPACT license preferred.
• Strong Utilization Management experience.
• 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

• Perform all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM).
• Serve as a single source of contact for members, health care personnel, and other entities involved in managing care.
• Conduct concurrent review, discharge planning, and care coordination.
• Identify alternate treatment programs and consult with physicians, providers, and members.
• Evaluate options and services required to meet an individual's health needs.
• Promote quality and cost-effective outcomes.
• Serve as a liaison to physicians and members.
• Provide episodic case management and determine member assignment of treatment.
• Conduct pre-admission/post-discharge counseling for acute conditions.
• Establish relationships with members during the post-discharge follow-up period.
• Provide education and local resource information to members.
• Encourage member self-education.
• Assess members for wellness education and disease management.
• Introduce members to website tools and educate them regarding wellness and specific conditions.

Benefits

• Health and wellness benefits.
• 401(k) savings plan.
• Pension plan.
• Paid time off.
• Paid parental leave.
• Disability insurance.
• Supplemental life insurance.
• Employee assistance program.
• Paid holidays.
• Tuition reimbursement.
• Annual incentive bonus plan.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree