Nurse Case Manager II

Must Reside in the Martinsville, Roanoke, Lynchburg, Danville
Telephonic and Field work. Candidates will need a quiet, dedicated work space with no distractions. Must have an active and unrestricted RN license in the state of Virginia or compact license.
The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes. Requires an RN with unrestricted active license

Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

Position Summary:

The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

Active Registered Nurse (RN) required; must hold a current, unrestricted Virginia nursing license in VA or compact license.

Duties:

Assessment of Members:
• Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
• Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
• Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.

Enhancement of Medical Appropriateness and Quality of Care:
• Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits
• Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
• Identifies and escalates quality of care issues through established channels
• Ability to speak to medical and behavioral health professionals to influence appropriate member care.
• Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health
• Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Helps member actively and knowledgably participate with their provider in healthcare decision-making
• Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.

Monitoring, Evaluation and Documentation of Care:
• In collaboration with the member and their care team develops and monitors established plans of care to meet the member's goals
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
• Majority of time is spent on telephonic outreach and documentation in a clinical case management platform.
Experience
3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
-Experience preferred managing chronic conditions, such as diabetes, hypertension, and asthma.
-Healthcare and/or managed care industry experience required.
-Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
-Effective communication skills, both verbal and written.
-Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
-Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
-Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
-Typical office working environment with productivity and quality expectations.
-Proficient in Microsoft Office Suite with high utilization of Microsoft Excel, Outlook, and Teams.
-Previous LOCERI experience a plus.

Experience:

Experienced Case Manager with a strong clinical background utilizing a collaborative, member-centered approach to assess, plan, and coordinate care. Skilled in conducting comprehensive assessments, interpreting clinical and benefits criteria, and developing individualized care plans that promote optimal, cost-effective health outcomes.

Demonstrates expertise in managing complex and chronic conditions, applying clinical judgment to identify risk factors, address barriers to care, and support appropriate utilization of services. Proficient in navigating managed care systems, regulatory guidelines, and interdisciplinary collaboration to ensure quality, compliant care delivery.

Highly effective in communication and engagement, using motivational interviewing and coaching techniques to empower members in healthcare decision-making and lifestyle changes. Adept at multitasking in fast-paced environments, with a strong focus on documentation, care coordination, and continuous monitoring to achieve positive member outcomes.

This role requires flexibility and the ability to support a large geographic coverage area, with significant travel expectations to complete in-person visits, meet program requirements, and ensure timely support of both members and team needs.

Education:

RN in VA with current unrestricted state licensure or compact license.

Case Management Certification CCM preferred