Telephonic Nurse Case Manager II

is responsible for 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.

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.
• Assists in problem solving with providers.
• Assists with development of utilization/care management policies and procedures.

Minimum requirements:

• Requires BA/BS in a health related field and minimum of 5 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.

For URAC accredited areas the following applies: Requires a BA/BS and minimum of 5 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background. Current and active RN license required in applicable state(s). Multi-state licensure is required if this individual is providing services in multiple states.

Preferred Capabilities, Skills, and Experiences:

• Certification as a Case Manager preferred.
• Ability to talk and type at the same time preferred.
• Demonstrate critical thinking skills when interacting with members preferred.
• Thrive in fast-paced environments; able to work across multiple applications/screens and multitask effectively (preferred)
• Strong organizational and prioritization skills in an ever-changing environment (preferred)
• Proficient in Microsoft 365/Microsoft Office Suite (Excel, SharePoint, Teams, Outlook) and Copilot; quick to learn new systems/software (preferred)
• Ability to manage, review and respond to emails/instant messages in a timely fashion preferred.
• 2 years' experience in acute care setting preferred.
• 2 years' "telephonic" Case Management experience with a Managed Care Company preferred.
• Managed Care experience preferred.