Registered Nurse (RN) Case Manager | Avera Health Plans Medical Management

Avera Health is seeking a specialized nurse for complex/chronic condition case management and service coordination.

About the role

The RN Case Manager will develop and facilitate a member's plan of care, collaborating with various stakeholders to ensure the best possible health outcomes. They will also manage transplant members across all phases of the process, including pre-, inpatient, and post-transplant care.

Responsibilities

• Identify cases for complex/chronic condition case management and service coordination based on data analysis.
• Create and execute personalized care plans aligned with NCQA standards.
• Perform utilization management activities such as preauthorizations, inpatient admissions, and retro reviews.
• Manage and authorize transplant members throughout all phases of the process.
• Review and interpret clinical and operational data to inform utilization management decisions.
• Communicate and collaborate with various departments within the health plan to resolve issues and improve care.
• Educate key stakeholders on benefit plan design and appropriate claims processing.
• Advocate for member health by recommending age-appropriate screenings and promoting wellness coverage.
• Research and identify community resources to address social determinants of health.

Requirements

• Registered Nurse (RN) license in the state of practice.
• Certified Case Manager (CCM) or Certified Managed Care Nurse (CMCN) certification within 3 years of hire.
• 4-6 years of nursing experience in an acute care setting.
• Ability to work the hours specified.

Qualifications

• Visual acuity adequate for position duties.
• Effective communication skills.
• Ability to hear, understand, and distinguish speech and other sounds.

Skills

• Knowledge of various health plan lines of business, including commercial, marketplace, and self-funded clients.
• Understanding of benefit plan design, network status, and appropriate claims processing.
• Experience working with health system stakeholders, key opinion leaders, vendors, and healthcare providers.

Benefits

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement.
• Hands-on training and mentorship for career development.