Case Manager, Registered Nurse
Core
Telephonic case manager supporting members across multiple states by applying clinical judgment to reduce risk factors, address complex health/social indicators, and ensure appropriate benefit administration.
Role type
Senior IC registered nurse case manager
Builds
Cost-effective quality care plans for fully and/or self-insured clients
Domain
Healthcare / Medical Management
Required skills
Clinical judgment, motivational interviewing, medical necessity review, regulatory compliance, electronic documentation, care plan development, risk factor reduction, multidisciplinary consultation, member engagement, benefits administration
Preferred skills
Case management experience, utilization review, oncology/transplant/specialty pharmacy/pediatrics/behavioral health experience, MCG/NCCN/Lexicomp proficiency, Spanish language
Technologies
MCG, NCCN, Lexicomp, Nurse Licensure Compact (NLC)
Responsibilities
Conduct telephonic case management for patients and care teams; apply clinical guidelines and regulatory standards to assess member needs; consult with supervisors and medical directors to overcome care barriers; perform medical necessity reviews; document care electronically; identify and escalate member needs per protocols; actively reach out to members to guide care.
Seniority
Mid-Senior level, hands-on IC