Registered Nurse (RN) Case Manager | Avera Health Plans Medical Management

Avera•Sioux Falls, SD

2d•Onsite

About The Position

Specialized nurse that identifies members who would benefit from complex/chronic condition case management and/or service coordination. The RN Case Manager develops and facilitates the member's plan of care. In collaboration with physicians, population health staff, employers, community organizations, hospital-based case managers/utilization review staff, clinic-based care coordinators/preauthorization staff, and Insurance Division staff, the RN Case Manager encourages the best possible outcome in the most cost effective manner in accordance with standards set forth by National Committee for Quality Assurance (NCQA). The RN Case Manager will need to be knowledgeable in various aspects of all health plan lines of business, inclusive of commercial, marketplace, and self-funded clients. The position requires interaction with health system stakeholders, key opinion leaders, vendors, delegated entities, healthcare providers, policy makers, and accreditation and government organizations.

Requirements

The individual must be able to work the hours specified.
To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
Registered Nurse (RN) - Board of Nursing
An active license in the state of practice Upon Hire
Certified Case Manager (CCM) - Commission for Case Manager Certification (CCMC) within 3 Years or Certified Managed Care Nurse (CMCN) - American Board of Managed Care Nurses (ABMCN) within 3 Years
4-6 years Nursing experience in acute care setting

Nice To Haves

Case management, disease management, care coordination or equivalent

Responsibilities

Identifies cases that qualify for complex/chronic condition case management and/or service coordination, based on, but not limited to, the evaluation of the following data: claims, hospital reports, risk stratification, utilization management, pharmacy reports, and referrals from internal health plan staff, clinic staff, hospital discharge planners, members and providers.
Creates and executes unique, care plans that ensure the best possible individualized health care goals for the chronic and/or complex member are met in accordance with NCQA assessment standards and requirements.
Performs utilization management activities of selected services, including preauthorizations, inpatient admissions, continued stay reviews and retro reviews using established medical guidelines, clinical information and clinical education to determine medical appropriateness for coverage.
Performs end to end management and authorization of all transplant members, in all phases of transplant (pre, inpatient, post). This includes authorization requests, case management services, claims inquiries, and network steerage.
Reviews and interprets key clinical and operational data in order to provide feedback and assist with the utilization management of healthcare services.
Effectively communicate and collaborate with other departments within the health plan including, but not limited to, clinical denials, appeals, network determination, and quality of care issues.
Understands and educates key stakeholders on benefit plan design, network status, and appropriate claims processing for approved services.
Directs and transitions care to network providers and coordinates service to ensure cost-effective, high-quality outcomes.
Advocates for member’s health by identifying age appropriate health screening(s), advising of wellness coverage benefits and facilitating member compliance with recommended screenings.
Researches and identifies community resources to assist in addressing all facets of social determinants of health.