Job Description

Job Responsibilities:

• The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.
• Through the use of clinical tools and data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services
• Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate
• administration of benefits
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

Skills:

• Years of Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
• Healthcare and/or managed care industry experience.
• Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
• Effective communication skills, both verbal and written.
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
• Sedentary work involves periods of sitting, talking, and listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
• Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.
• Typical office working environment with productivity and quality expectations

Education/Experience:

• AA degree in nursing min; Bachelors preferred; Licensed Registered Nurse

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