RN Case Management Coordinator

About the role

The Case Management Coordinator role focuses on improving care coordination and reducing fragmentation among clients. The position aims to enhance client safety, well-being, and quality of life by recommending cost-effective and efficient care options. The coordinator works closely with clients, families, and healthcare providers to manage care plans and ensure adherence to medical necessity and benefit guidelines.

Responsibilities

• Provides active care management, assesses service needs, and develops and coordinates action plans.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services.
• Ensures accurate documentation of clinical information to support medical necessity criteria and contract benefits.
• Offers telephonic support for members with chronic conditions, high-risk pregnancies, or other at-risk conditions.
• Participates in direct intervention and patient education with members and providers regarding health care delivery systems and benefit plans.
• Serves as a member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• Communicates with health care providers and members regarding requested services.
• Performs medical or behavioral review/authorization process and ensures coverage for appropriate services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determinations and identifies and makes referrals to appropriate staff.
• 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.
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
• Assists 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 specialty areas such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedics, general medicine/surgery.
• 4 years recent clinical experience in defined specialty areas or 4 years of utilization review/case management/clinical experience, with 2 years being clinical.
• 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.

Qualifications

• 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 counselor, or psychologist from the United States and in the state of hire (in Div. 75 only).
• URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager.

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 educational assistance and national discounts to various attractions and entertainment venues. Additionally, we offer a variety of services and programs designed to support employee development and career advancement.