Registered Nurse (RN) Case Manager | Avera Health Plans Medical Management

Registered Nurse Case Manager

Location: Avera Health Plans

Worker Type: Regular

Work Shift: Day Shift (United States of America)

Pay Range: $31.00 - $46.25

Position Highlights

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

What You Will Do

• Identifies cases that qualify for complex/chronic condition case management and/or service coordination, based on, but not limited to, the evaluation of the following data: claims, hospital reports, risk stratification, utilization management, pharmacy reports, and referrals from internal health plan staff, clinic staff, hospital discharge planners, members and providers.
• Creates and executes unique, care plans that ensure the best possible individualized health care goals for the chronic and/or complex member are met in accordance with NCQA assessment standards and requirements.
• Performs utilization management activities of selected services, including preauthorizations, inpatient admissions, continued stay reviews and retro reviews using established medical guidelines, clinical information and clinical education to determine medical appropriateness for coverage.
• Performs end to end management and authorization of all transplant members, in all phases of transplant (pre, inpatient, post). This includes authorization requests, case management services, claims inquiries, and network steerage.
• Reviews and interprets key clinical and operational data in order to provide feedback and assist with the utilization management of healthcare services.
• Effectively communicate and collaborate with other departments within the health plan including, but not limited to, clinical denials, appeals, network determination, and quality of care issues.
• Understands and educates key stakeholders on benefit plan design, network status, and appropriate claims processing for approved services.
• Directs and transitions care to network providers and coordinates service to ensure cost-effective, high-quality outcomes.
• Advocates for member's health by identifying age appropriate health screening(s), advising of wellness coverage benefits and facilitating member compliance with recommended screenings.
• Researches and identifies community resources to assist in addressing all facets of social determinants of health.

Essential Qualifications

• The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

• Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire and
• Certified Case Manager (CCM) - Commission for Case Manager Certification (CCMC) within 3 Years or
• Certified Managed Care Nurse (CMCN) - American Board of Managed Care Nurses (ABMCN) within 3 Years
• 4-6 years Nursing experience in acute care setting

Preferred Education, License/Certification, or Work Experience:

• Case management, disease management, care coordination or equivalent

Expectations and Standards

• Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera's values of compassion, hospitality, and stewardship.
• Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement
• Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call View phone number on click.appcast.io or send an email to View email address on click.appcast.io.