Nurse Case Manager I

Nurse Case Manager I

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Nurse Case Manager I will be responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically for discharge planning.

How you will make an impact:

• Ensures member access to services appropriate to their health needs.
• Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
• Coordinates internal and external resources to meet identified needs.
• Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
• Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
• Negotiates rates of reimbursement, as applicable.
• Assists in problem solving with providers, claims or service issues.
• Ensure compliance with healthcare regulations and monitor adherence to contractual obligations.
• Ability to handle unexpected changes in assignments and members needs and manage a flexible schedule accommodating field visits and emergency situations.
• Valid driver's license, reliable transportation, and ability to travel within the service area as needed.
• Conduct facility, hospital, or home visits to monitor and evaluate care as applicable and/or required.
• Maintaining meticulous records of interactions, decisions, and care plans for compliance and audit purposes.
• Proficiency in using mobile devices, multiples systems, and technology to access member records, document visits and reports, and communicate with the central office.
• Competence in addressing quickly arising issues effectively, often requiring creative and immediate solutions.

Minimum Requirements:

• Requires BA/BS in a health related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current, unrestricted RN license in applicable state(s) required.
• Multi-state licensure is required if this individual is providing services in multiple states.

Preferred Skills, Capabilities, and Experiences:

• Certification as a Case Manager is preferred.
• Prior hospital experience is preferred.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse