LOCATION: This is a remote opportunity and you must be within 50 miles of our Hanover, Maryland office. Maryland residency is required.
HOURS: General business hours, Monday through Friday: 8:30 am - 5:30 pm
TRAVEL: Occasional visits to the office may be required for team meetings or training.
The Nurse Case Manager I is responsible for performing care management within the scope of licensure for members with complex and chronic care. Responsible for those members at highest risk for a rapid readmission, thus promptly engaging them to assess and address red flags, improve the quality of care, and allow for real-time oversight. Performs duties telephonically.
Primary duties may include, but are not limited to:
- 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.
- Negotiates rates of reimbursement, as applicable.
- Assists in problem solving with providers, claims or service issues.
Required Qualifications
- Requires BA/BS in a health related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
- Current, unrestricted RN license from the state of Maryland is required.
Preferred Qualifications
- Previous pediatric nursing experience is must for this role!
- Previous experience as a case manager is strongly preferred.
- Previous Medicaid and/or Managed Care experience is very helpful.
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