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. 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.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.