Case Management RN

Overview

Role Snapshot:
Our Case Management RN coordinates care and services of select member populations with complex health care needs across continuum of care. The primary focus is the development and continuous monitoring of a member-centric plan of care that promotes effective utilization of health care services while maximizing quality and cost-efficiency. The Case Management RN educates members and family members on plans of care and serves as a liaison between members, their families, and health care providers.

Salary Range: $75,000 ~ $100,000. The base pay offered may vary based on job-related knowledge, skills, and experience. Remote work is open in the following approved states:
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin.

If you:

• Have developed and implemented individualized care plans and set short-term and long-term goals for case-managed members.
• Enjoy reviewing and providing prior authorization decisions for selective high-cost services including transplant, dialysis, and CAR-T/gene therapy.
• Have interfaced with utilization management for select authorization services.
• Act as an advocate for the member’s needs and preferences and identify/address barriers to care.
• Coordinate medical services and resources, facilitate transitions of care between settings, and assist with site of care redirections as needed.
• Help members manage conditions and address unique issues during care transitions.
• Educate members and caregivers on community resources, how to prepare for physician visits, and how to overcome barriers and achieve medication compliance.
• Assess motivational or psychosocial issues for case-managed members and support them to achieve wellness and autonomy.
• Identify legal or liability issues and refer potential ethical or risk management issues to the appropriate department for review and resolution.
• Document all care management activities and analyze/report care management activities, including high-risk, high-cost, and high-utilization cases.
• Maintain accurate, up-to-date case notes, care plans, and other documentation in compliance with health plan guidelines, state, and federal regulations.
• Work cross-functionally to support other departmental efforts to ensure overall efficiency, quality, productivity, and compliance with all standards.

• Registered Nurse (RN) with current licensure in the state of Wisconsin OR current Compact License.
• 4 or more years of experience as a Registered Nurse in varied clinical settings (e.g., hospital, clinic, home care, skilled nursing facility).
• 2 or more years of case management experience.
• Demonstrated experience managing and coordinating care effectively for case-managed members.
• Strong knowledge of clinical care management processes, care coordination, and case management principles.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Strong diverse experience and expertise including the ability to work independently, manage a caseload, and prioritize tasks; excellent analytical, critical thinking, problem-solving, and decision-making skills; excellent communication and interpersonal skills; proficiency in Microsoft Office and healthcare software and systems.

• Bachelor's degree in nursing (BSN).
• Health insurance background in POS, PPO, or Medicare Supplement plans preferred.
• Certified Case Manager (CCM) preferred.
• Technical experience with word processing, spreadsheets, and EMR systems and/or other managed care software.

• High-speed cable or fiber internet.
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream (check at ).
• Review Remote Worker FAQs for additional information.

• Remote work options available.
• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first 3% of salary and a 50% match for the next 2% (100% vested immediately).
• Competitive paid time off.
• Health, dental, and telehealth services start DAY 1.
• Professional and Leadership Development Programs.
• A…