Coordinate all aspects of the care of individual members. Ensure proper utilization of services and resources. Review of prior authorization requests for appropriateness of care within established evidence base criteria sets. Provide assistance within, between, and outside of facilities. Facilitate outstanding member care using fiscally responsible strategies. Collaborate closely with physicians, nurses, social workers and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services. Assess the member’s specific health plan benefits and the additional medical, community, or financial resources available.
Work Experience: Five years of nursing experience with varied medical exposure and experience preferred. Experience in acute care, case management, including cases that require rehabilitation, home health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required.
Education, Certificates, Licenses: Registered Nurse with current unrestricted state license. [Oregon license required at time of hire; Montana and Idaho required within 6 months of hire.) Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification) preferred.
Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes including ICD 10 and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Working knowledge of community services, providers, vendors and facilities available to assist members. Understanding of, and ability to create appropriate case management plans. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. Must be able to function as part of a collaborative, cohesive team.
Additional Salary Information: Exceptional health and retirement package, quarterly bonus program and generous vacation accrual.