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Nurse Care Mgr IILocation: United StatesNewRequisition #: PS28711Please Note: Associates in this job are paid hourly and are eligible for overtime. Responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers.Performs care management activities within the scope of licensure for members with complex and chronic care needs.Primary duties may include, but are not limited to:
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting and level of care.
Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance. Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.
Conducts clinical assessment to develop goals that address individual needs in order to develop a care plan; implements and coordinates a care plan.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Assists with development of utilization/care management policies and procedures.
Participates in or leads intradepartmental teams, projects, and initiatives. accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice.
Will be working Monday-Friday, 9:00AM-6:00 PMRequires 3 years of acute care clinical experience , condition specific clinical experience, home health/discharge planning experience; at least 1 year in a Nurse Care Mgr I role or equivalent experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required.Multi-state licensure is required if this individual is providing services in multiple states . AS/BS in nursing preferred. Certification as a Case Manager is preferred.Participation in the American Association of Managed Care Nurses preferred. Prior managed care experience preferred.Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice.Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background, Multi-state licensure is required if this individual is providing services in multiple states . Certification as a Case Manager from the approved list of certifications or a BS in a health or human services related field, also preferred.
