Case Manager RN - Level I - Bilingual

Scope The Case Manager manages an individual caseload using the Case Management process to meet the needs of MedWatch, LLC customers and consumers. This includes authorization of services, review of treatment plans for medical necessity, standards of care, and ongoing communication with all members of the health care team. Education R.N. Bachelor's degree in a health‑related field preferred. Licensure/Certification Requirements Registered Nurse (current active and unrestricted, in state of current practice and residence, within the United States or its territories.) Experience 7 years of varied clinical experience preferred. Requirements / Skills Good organizational skills and time management Excellent verbal and written communication skills Ability to handle difficult situations tactfully and diplomatically. Effective problem solving and decision‑making skills. Strong computer skills with proficiency in MS Office Suite (Word, Excel, PowerPoint) Must speak fluent English and Spanish with strong reading and writing abilities in each language. Expectations of a Level I RN Case Manager Focus: Managing moderate‑complexity cases independently and contributing to team goals. Key Responsibilities Meet entry‑level criteria Independently manage a full caseload Coordinate care transitions and discharge planning Collaborate with providers, social workers, and insurance teams Participate in quality improvement initiatives Development Goals Demonstrate consistent documentation and compliance Show initiative in problem solving and patient advocacy Function independently and demonstrate proficiency in managing case‑management case load Duties and Responsibilities The Registered Nurse Case Manager will practice within the scope of his/her licensure. Review all medical data provided to establish, update, and maintain accountability for a Case Management plan, incorporating contact with providers, payers, the patient, and with the patient’s primary caregiver. Assess problems and determine goals and actions designed to meet the needs of the patient, documenting these into the case notes. Determine if goals are long‑term or short‑term and how the patient can be expected to meet them; include the actions/interventions the Case Manager will take to work toward achieving those goals. Make contact with the payer office to find out and understand any benefit constraints that will have an impact on the plan of action. Proceed with contacting medical care providers and equipment vendors to verify medical necessity of care or equipment that has been ordered. Make care arrangements for quality patient care according to the needs of the patient, the physician's orders, and the benefits available. Work in conjunction with the Case Management Assistant to manage Case Management files, exclusive of Assessment and/or Care Plan activities, and provide input in the Annual Performance Evaluation of the CM Assistant assigned. Be aware of any alternative treatment possibilities that may allow the patient to reach wellness goal(s); if there are no benefits available for recommended alternative treatments, provide to the payer a cost‑benefit analysis demonstrating that extra‑contractual services will enhance the patient’s medical condition and be cost‑effective to the benefit plan. Become familiar with community resources and funding sources so that the patient can receive quality health care and conserve health benefit dollars. Maintain case in computer system, documenting case actions for each patient under your Case Management, completing all aspects of the case in the computer; prepare timely reports to the payer detailing all case actions, results, and the continuing Case Management plan. Maintain billing as appropriate in the computer system. Continue to maintain contact with the providers and the patient across the continuum of care to be sure that patient needs are being met; on any cases with a chronic condition keep the file open for periodic contacts to verify clinical status and additional needs. Negotiate with providers to maximize the medical benefits available to the patient; make network referral as appropriate. Act upon any awareness of non‑medical issues involving patient safety or welfare; attempt to direct the patient or family to appropriate providers or community resources, or personally notify relevant authorities. Consult with the Director of Case Management on a regular basis and keep the supervisor informed regarding any complaints or issues that may arise which the Case Manager is not competent or capable to handle. Adhere to all company policies as stated in the employee handbook. All Case Managers will possess a URAC‑recognized certification in Case Management within 3 years of hire. Participate in the Quality Management Program by adhering to all company policies and procedures and identifying opportunities for improvement to ensure quality services to clients and customers. Other Compensation and Benefits The incumbent may be responsible for duties or responsibilities that are not listed in this job description; duties may change at any time with or without notice. This position is eligible for a bonus program. There is a pay differential for bilingual Spanish speaking requirement. The salary range for this position is from $72,000 to $81,000 annually. Work Environment / Physical Demands This position is in a typical office/home office environment that requires prolonged sitting in front of a computer. Requires hand‑eye coordination and manual dexterity sufficient to operate standard office equipment, including computer and phone equipment. We are an Equal Opportunity Employer, including disability/veterans. #J-18808-Ljbffr MedWatch, LLC