Case Manager; Acutes​/RN

Overview

The Case Manager manages an individual caseload using the case management process to meet the needs of Med Watch, LLC customers and consumers. This includes authorization of services, review of treatment plans for medical necessity and standards of care, and ongoing communication with all members of the health care team. This is a remote/work-from-home position. This position requires licensure in all 50 states (including states not included in the compact license).

• Being licensed in all 50 states including states not included with the compact license

• RN, a bachelor’s degree in a health-related field preferred

• 7 years of varied clinical experience preferred

• The Registered Nurse Case Manager will practice within the scope of licensure.
• Review all medical data to establish, update and maintain accountability for a case management plan, including contact with providers, payers, the patient, and the patient’s primary caregiver.
• Assess problems and determine goals and actions designed to meet the patient’s needs and document into the case notes. Determine if goals are long-term or short-term and the steps required to achieve them.
• Contact the payer to understand benefit constraints affecting the plan of action.
• Contact medical care providers and equipment vendors to verify medical necessity of care or equipment ordered.
• Make care arrangements for quality patient care according to patient needs, physician orders, and available benefits.
• Work with the Case Management Assistant to manage case management files (excluding Assessment and/or Care Plan activities) and provide input in the Annual Performance Evaluation of the CM Assistant. Maintain responsibility for the Case Management file.
• Explore alternative treatment possibilities to help the patient reach wellness goals. If no benefits are available, provide the payer with a cost-benefit analysis for extra-contractual services when cost-effective to the benefit plan.
• Familiarize with community resources and funding sources to ensure quality health care and conservation of health benefit dollars.
• Maintain case documentation in the computer system and prepare timely reports to the payer detailing actions, results, and continuing plan.
• Maintain billing as appropriate in the computer system.
• Stay in contact with providers and the patient across the continuum of care to ensure needs are met; for chronic conditions keep the file open for periodic contacts to verify status and needs.
• Negotiate with providers to maximize medical benefits and make network referrals as appropriate.
• Address non-medical issues impacting safety or welfare; direct the patient or family to appropriate providers or resources, or notify authorities when necessary. Consult with the CM supervisor regularly and report any complaints or issues beyond the case manager’s competence to handle.
• Adhere to all company policies as stated in the employee handbook.
• All case managers will possess a URAC-recognized certification in Case Management within 3 years of hire. Participate in the Quality Management Program by adhering to policies and identifying opportunities for improvement to ensure quality services are rendered.
• This position is eligible for a bonus program.

The salary range for this position is from $72,000 to $81,000 annually.

Work from a typical home office environment which requires prolonged sitting in front of a computer. Requires hand-eye coordination and manual dexterity to operate standard office equipment, including computer and phone equipment.

We are an Equal Opportunity Employer, including disability/veterans.