The Nurse
Case Manager is 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
and ensuring member access to services
appropriate to their health needs.
Job
Description:
The Nurse
Case Manager will perform
all or some of the following Job
description:
Conduct assessments to identify
individual needs and a specific care
management plan to address
objectives and goals as identified
during assessment
Implement care plan by facilitating
authorizations/referrals as
appropriate within benefits
structure or through
extra-contractual arrangements
Coordinate internal and external
resources to meet identified needs
Monitor and evaluate effectiveness
of the care management plan and
modify as necessary
Interface with Medical Directors and
Physician Advisors on the
development of care management
treatment plans
Negotiate rates of reimbursement, as
applicable
Assist in problem solving with
providers, claims or service issues
Assist with development of
utilization/care management policies
and procedures.
Minimum Requirements / Knowledge /
Skill For Nurse Case Manager Job
5
years clinical experience
Knowledge of health
insurance/benefits
Knowledge of care management
assessment technique, provider
community, and community resources
3
years experience in home
health/discharge planning
Strong oral, written and
interpersonal communication skills
PC
skills to include word processing,
spreadsheet, and database
applications
Organizational and problem-solving
skills, and decision-making skills
Ability to be licensed in multiple
states on a timely basis
2-3
years experience as Case Manager or
UM Nurse
WMDS
& WGS experience.
Minimum Education Requirements /
Certification / Licensure For Nurse Case
Manager Job
BA/BS or higher in a health related
field and licensure as a health
professional, or certification as a
care manager, or current
unrestricted RN license in
applicable state(s).
