Case Management RN

Overview

Role Snapshot Our Case Management RN (Registered Nurse) coordinates care and services of select member populations with complex health care needs across continuum of care. The primary focus of the role 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 of these services for members.

Our Case Management RN educates members and family members on plans of care while serving as a liaison between the members, their families and health care providers.

Salary Range $75,000 ~ $100,000. The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

We are open to remote work 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.

How do I know this opportunity is right for me? If you:

• Have developed and implemented individualized care plans, short term and long-term goals for case managed members.
• Enjoy reviewing and providing prior authorization decisions for selective high-cost services including but not limited to transplant, dialysis, CAR-T/gene therapy.
• Have interfaced with utilization management for select authorization services.
• Would like serving as an advocate for the member’s needs and preferences and can identify and address barriers to care.
• Would like to coordinate medical services and resources, facilitate transitions of care between settings, and assist with site of care redirections as needed.
• Can help members manage their conditions and address unique issues during their care transitions.
• Enjoy educating members and caregivers on appropriate and available community resources, how to prepare for physician visits, and how to overcome barriers and achieve medication compliance.
• Can assess motivational or psychosocial issues for case managed members and facilitate case management members to achieve wellness and autonomy.
• Have the ability to identify legal or liability issues and refer potential ethical or risk management issues to the appropriate department for review and resolution.
• Can document all care management activities and analyze/report care management activities, including identification of high risk, high cost and high utilization cases.
• Have maintained accurate, up-to-date case notes, care plans, and other documentation in compliance with health plan guidelines, state, and federal regulations.
• Can work cross-functionally to support other departmental efforts to ensure overall efficiency, quality, productivity and compliance with all departmental and regulatory 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 (i.e., hospital, clinic, home care, skilled nursing facility, etc.).
• 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 that includes:
  • The ability to work independently, manage a case load, and prioritization.
  • Excellent analytical, critical thinking, problem-solving skills and decision-making skills.
  • Excellent communication and interpersonal skills to work with members, providers, and teams
  • Proficiency in Microsoft Office and healthcare software and systems.

• Bachelor’s degree in nursing (BSN).
• Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement plans preferred.
• Certified Case Manager (CCM) preferred.
• Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software.