Nurse Case Manager Lead

About the role

The Telephonic Nurse Case Manager Lead role involves conducting assessments, developing and implementing care plans, coordinating resources, and interfacing with medical directors and physician advisors. The position requires a BA/BS in a health-related field and 5 years of clinical experience, with a current, unrestricted RN license and case manager certification.

Responsibilities

• Conducts assessments to identify individual needs and develop care management plans.
• Facilitates authorizations and referrals as needed within the benefits structure or through extra-contractual arrangements.
• Coordinates internal and external resources to meet identified needs.
• Maintains and evaluates the effectiveness of care management plans, modifying as necessary.
• Negotiates rates of reimbursement, as applicable.
• Solves problems with providers, claims, or service issues.
• Develops and implements utilization/care management policies and procedures.
• Participates in audit activities and assists with management of day-to-day activities.
• Serves as a first-line contact for conflict resolution.
• Develops training materials, completes quality audits, performs process evaluations, and tests and monitors systems/process enhancements.

Requirements

• Requires a BA/BS in a health-related field and 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Absolutely current, unrestricted RN license in applicable state(s) required.
• Certification as a Case Manager is preferred.
• A BS in a health or human services related field preferred.
• Managed care experience necessary.
• Case management experience a plus.

Qualifications

• Minimum of 5 years of clinical experience.
• Current, unrestricted RN license in applicable state(s).
• Certification as a Case Manager preferred.
• Bachelor's degree in a health or human services related field preferred.
• Managed care experience necessary.
• Case management experience a plus.

Skills

• Comprehensive knowledge of specific disease processes or traumatic injuries.
• Functions as a preceptor for new care management staff.
• Ability to negotiate rates of reimbursement.
• Experience in problem-solving with providers, claims, or service issues.
• Knowledge of utilization/care management policies and procedures.
• Experience in developing and implementing care management plans.
• Experience in conducting assessments and developing care management plans.
• Experience in interfacing with medical directors and physician advisors.
• Experience in coordinating internal and external resources.
• Experience in monitoring and evaluating care management plans.
• Experience in negotiating rates of reimbursement.
• Experience in assisting with development of utilization/care management policies and procedures.
• Experience in participating in audit activities.
• Experience in serving as a first-line contact for conflict resolution.
• Experience in developing training materials.
• Experience in completing quality audits.
• Experience in performing process evaluations.
• Experience in testing and monitoring systems/process enhancements.

Benefits

• Market-competitive total rewards package including merit increases, paid holidays, Paid Time Off, and incentive bonus programs.
• Medical, dental, and vision coverage.
• Short and long-term disability benefits.
• 401(k) match.
• Stock purchase plan.
• Life insurance.
• Wellness programs and financial education resources.

Pay

$X per hour or $Y per year, depending on the specific role and location.

Schedule

Monday - Friday, 11:30- 8 pm EST.