Case Management Coordinator (RN or Social Worker)

About the role

The Case Management Coordinator role focuses on improving care coordination and reducing fragmentation among clients, aiming to enhance safety, well-being, and quality of life. Care management interventions are designed to align with the "Triple Aim" objectives: improving health outcomes, enhancing patient experiences, and reducing healthcare costs.

Responsibilities

• Provides active care management, assesses service needs, develops and coordinates action plans, monitors services, and implements plans, including member goals.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Provides telephonic support for members with chronic conditions, high-risk pregnancies, or other at-risk conditions, involving intensive assessments, educational sessions, and motivational interviewing techniques.
• Participates in direct intervention and patient education with members and providers regarding health care delivery systems, utilization on networks, and benefit plans.
• Makes on-site reviews and serves as a member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• Communicates appropriately (written, telephone) regarding requested services to both health care providers and members.
• Performs medical or behavioral review/authorization process, ensuring coverage for appropriate services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determinations, identifies and makes referrals to appropriate staff, and participates in data collection/input into system for clinical information flow and proper claims adjudication.
• Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, including ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
• Affords assistance with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.

Requirements

• Associates in a job-related field or equivalent 2 years of recent clinical experience in defined specialties such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery.
• 4 years of recent clinical experience in utilization review, case management, clinical, or combination roles, with 2 of the 4 years being clinical.
• Knowledge of word processing software, quality improvement processes, contract language, independent work, prioritization, decision-making, judgment, customer service, organization, and communication skills.
• Working knowledge of spreadsheet, database software, claims/coding analysis, and processes.
• Active unrestricted RN license from the United States and in the state of hire OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) OR, active, unrestricted licensure as social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as counselor or psychologist from the United States and in the state of hire (in Div. 75 only).

Qualifications

• Preferred: 7 years of healthcare program management.
• Preferred: Working knowledge of spreadsheet, database software, claims/coding analysis, and processes.
• Preferred: Case Manager certification, clinical certification in specialty area.

Skills

• Working knowledge of word processing software.
• Knowledge of quality improvement processes and demonstrated ability with these activities.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.

Benefits

We offer a comprehensive benefits package including subsidized health plans, dental and vision coverage, a 401k retirement savings plan with company match, life insurance, paid time off (PTO), on-site cafeterias and fitness centers, and more. We also provide reasonable accommodations for individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.