Nurse Case Manager

Embark on a Journey That Makes a Difference. At Generali Global Assistance (GGA), every day is an opportunity to help people explore the world with confidence. We’re not just in the business of protection—we’re in the business of adventure and peace of mind. Whether it’s a backpacker trekking through the Andes, a family cruising the Mediterranean, or a solo traveler chasing the Northern Lights, we’re there to ensure their journey is safe and supported. From assisting with emergency medical claims to guiding customers through trip disruptions or ID theft, your work helps turn travel challenges into stories of resilience. Set Sail on a Career Path to Success. Our Teams Value Curiosity And Collaboration While Priding Ourselves On Fostering a Welcoming And Inclusive Atmosphere For Our Employees. Elevate Your Journey Through Our Internal Programs, Including: Diversity, Equity, and Inclusion (DEI) Committee Career pathing and Individual Development Plans Internal training and intern opportunities Women in Business Mentorship Program Employee awards and recognition Education and professional development assistance program Passport To Perks Includes Generous Employer contribution for health, dental, and vision insurance Paid Maternity and Paternity Leave Scholarship Program for Employee Dependents Company match on 401k Employee Assistance Program (EAP) Company paid short-term and long-term disability insurance Company paid life insuranceVoluntary Pet Insurance Voluntary Legal Benefit Discounts on travel insurance Time off policies including vacation days, sick days, personal days, holidays and volunteer days (VTO) Your Role On The Expedition The Medical Case Manager is a Licensed Practical Nurse or a Registered Nurse who is accountable and capable of securing and reviewing clinical data in order to approve requests for admissions, procedures and services that meet clinical review criteria. Ensures that there is coordination and delegation of care between all providers involved. Ensure that procedures / services are not duplicated and that services being rendered fall within the industry standards of care. The Medical Case Managers responsibilities include but are not limited to: assessment of strengths and weaknesses, implementation of a treatment plan, coordination and availability of resources, familiarity with the insured policy and its’ limitations and the communication and documentation with the appropriate entities that require information as per the stated policies and procedures while adhering to HIPAA and/or GDPR compliance. The Medical Case Manager (UR/UM/CM) is NOT financially incentivized for decisions that result in underutilization, adverse determinations and / or denials. Chart Your Course Collects client data and conducts emergent and non-emergent clinical assessment. Assists in the referral of patients to most appropriate provider specialty / facility within Network. Monitors and screens pre-authorization requests for second medical opinion referrals and/or diagnostic testing. Reviews hospital admissions for medical necessity and assigns LOS in accordance with established criteria. Sends out appropriate communication to providers, facilities and/or client. Refers all cases that do not fall within pre-established criteria to the Supervisor for further evaluation and determination of admission approval, procedure or services requested or refer to Medical Director or peer reviewer. Medical Case Managers do not issue non-certifications (denials). Once it is determined that an admission, procedure or service should be denied; assists in assuring that verbal or written denial notices are distributed out to the appropriate parties in a timely manner. Performs duties of the discharge planning nurse to contain LOS and assure that the insured (member/patient) is receiving services within the 6 Rights: Care, Place, Time, Provider, Price and Outcome. Assist with the coordination (within all phases) of a repatriation /evacuation and work in accordance to individual Client Procedures as well as internal GMMI Work Instructions and/or Standard Operating Procedures. Report any change in insureds (member/patient) condition IMMEDIATELY in order to make any differing change in plans. Enters and maintains all applicable information related to a case in GMMI’s operating software. Evaluates and reviews treatment plan for consistency of care. Develops realistic treatment plan in conjunction with provider recommendations in order to meet the client’s needs while providing the most appropriate and cost effective method of delivering services. Evaluates and determines the availability of resources in conjunction with policy limits and coverage. Implements cost management and delivers the most effective treatment plan. Maintains current knowledge base with regard to medical-surgical cases, utilization management, discharge planning and continued care needs in relation to physician approved criteria. Case Manager is to expand knowledge base and become familiar with ICD-10 and how it improves cost containment efforts due to specificity. Responsible for updating the “Tracker” system and for the timely follow up on each case that is monitored in the tracker. Functions as a clinical resource to non-clinical staff. Required Qualifications High School Diploma or Equivalent (GED) required. Licensed health professionals: LPN or RN. Active license in the state of Florida. Keep license current and complete CEU’s as mandated by the Board of Nursing in the state of Florida At least two-year's experience in the field of Managed Care or related acute care areas; Medical/Surgical, OB/GYN, Pediatrics, Cardiology, Neurology, Nephrology, Orthopedics, Transplant and/or CCU/ICU. Maintains confidentiality of all pertinent client/member (patient) information. Strong organizational and time management skills required – with emphasis on prioritizing and performing multiple tasks in unison. Excellent communication skills (verbal and written). Exercises and displays the ability to interact effectively with physicians, providers, internal staff and insureds’ as deemed necessary. Preferred Qualifications Bilingual (any language) Position Coordinates This is a hybrid role based out of our Pembroke Pines, FL office. As a hybrid role, you will be working onsite 2-3 days a week and working from home 2-3 days a week. One team. Every destination. Generali Global Assistance Is Proudly Part Of The Europ Assistance Group And Our Products Utilize a Number Of Corporate And Product Brands. The Brands For Our North American Team Include The Following: CSA: US travel insurance brand for retail, tour operator, cruise and lodging partners. Learn more here. Generali Global Assistance (GGA): The primary Corporate brand in the United States for our travel insurance, travel assistance, identity and cyber protection, and beneficiary companion products. Learn more here. GMMI: the industry standard for global medical cost containment and medical risk management solutions. Learn more here. Iris, Powered by Generali: identity and digital protection solution. Learn more here. Explore new horizons – apply today! Don’t meet every single requirement? At Generali Global Assistance, we are dedicated to building a diverse, inclusive and enriching workplace, so if you’re excited about this role but your past experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyways. You may be just the right candidate for this or other roles. The Company is committed to providing equal employment opportunity in all our employment programs and decisions. Discrimination in employment on the basis of any classification protected under federal, state, or local law is a violation of our policy. Equal employment opportunity is provided to all employees and applicants for employment without regard age, race, color, religion, creed, sex, gender identity, gender expression, transgender status, pregnancy, childbirth, medical conditions related to pregnancy or childbirth, sexual orientation, national origin, ancestry, ethnicity, citizenship, genetic information, marital status, military status, HIV/AIDS status, mental or physical disability, use of a guide or support animal because of blindness, deafness, or physical handicap, or any other legally protected basis under applicable federal, state, or local law. This policy applies to all terms and conditions of employment, including, but not limited to, recruitment and hiring, classification, placement, promotion, termination, reductions in force, recall, transfer, leaves of absences, compensation, and training. Any employees with questions or concerns about equal employment opportunities in the workplace are encouraged to bring these issues to the attention of Human Resources. The Company will not allow any form of retaliation against individuals who raise issues of equal employment opportunity. All Company employees are responsible for complying with the Company’s Equal Opportunity Policy. Every employee is to treat all other employees equally and fairly. Violations of this policy may subject an employee to disciplinary action, up to and including termination of employment. #J-18808-Ljbffr