Nurse Case Manager I

About the role

The Nurse Case Manager I is responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning.

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Responsibilities

• Ensures member access to services appropriate to their health needs
• Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
• Coordinates internal and external resources to meet identified needs
• Monitors and evaluates effectiveness of the care management plan and modifies as necessary
• Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans
• Negotiates rates of reimbursement, as applicable
• Assists in problem solving with providers, claims or service issues

Requirements

• BA/BS in a health related field and minimum of 3 years of clinical 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
• For URAC accredited areas: BA/BS and 3 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background; current and active RN license required in applicable state(s); multi-state licensure is required if providing services in multiple states

Preferred qualifications

• Certification as a Case Manager is preferred
• Experience with home health or Med-Surg is preferred
• Bilingual is strongly preferred

Pay and benefits

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.