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Care Manager RN - Remote ID-24581

JOB SUMMARY

This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

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Β 

ESSENTIAL RESPONSIBILITIES

  • Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.
  • Function in accordance with applicable state, federal laws and regulatory compliance.
  • Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
  • Promote quality and efficiency in the delivery of care management services.
  • Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.
  • Practice within the scope of ethical principles.
  • Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
  • Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member.
  • Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
  • Develop and sustain positive working relationships with internal and external customers.
  • Utilize outcomes data to improve ongoing care management services.
  • Other duties as assigned or requested

Β 

EDUCATION

Required

  • None

Β 

Substitutions

  • None

Β 

Preferred

  • Bachelor’s Degree in Nursing

Β 

EXPERIENCE

Required

  • 3 years of related, progressive clinical experience in the area of specialization
  • Experience in a clinical setting

Β 

Preferred

  • Experience in UM/CM/QA/Managed Care

Β 

LICENSES AND CERTIFICATIONS

Required

  • Current RN state licensure required.Β  Additional specific state licensure(s) may be required depending on where clinical care is being provided.

Β 

Preferred

  • Certification in utilization management or a related field

Β 

SKILLS

  • Working knowledge of pertinent regulatory and compliance guidelines and medical policies
  • Ability to multi task and perform in a fast paced and often intense environment
  • Excellent written and verbal communication skills
  • Ability to analyze data, measure outcomes, and develop action plans
  • Be enthusiastic, innovative, and flexible
  • Be a team player who possesses strong analytical and organizational skills
  • Demonstrated ability to prioritize work demands and meet deadlines
  • Excellent computer and software knowledge and skills

Β 

Languages (Other than English)

None


Travel Requirement

0% - 25%

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