Oregon IS NOT a compact state

Active Oregon Nursing License is required

Active OR RN License required

Position Summary:

This position revolves around the personalized, timely, comprehensive, and cost-effective

approach to member health related services. The Nurse Case Manager (NCM) collaborates

with a variety of people and entities including, but not limited to providers, pharmacies,

vendors, care facilities, hospitals, and other community services. The NCM uses judgement

in selecting appropriate guidelines and in applying general policies and procedures. The NCM

performs prospective, concurrent, and retrospective reviews of inpatient, outpatient,

ambulatory, and ancillary services to ensure medical necessity, appropriate length of stay,

intensity of service, and level of care. May establish care plans and coordinate care through

the health care continuum including member outreach assessments.

The NCM provides a variety of nursing services, predominately by phone, to address acute

and chronic needs of our health plan members.

Reporting Accountability: Reports to Director of Medical Management

Primary Role and Responsibilities:

 Analyze, research, respond to, and prepare documentation related to retrospective

review requests and appeals in accordance with local, state, and federal regulatory

standards.

 Contact appropriate medical and support personnel to identify and recommend

alternative treatment, service levels, length of stays, etc. using approved clinical

protocols.

 Establish, coordinate, and communicate discharge planning needs with appropriate

internal and external entities.

 Work with the Medical Director to determine medical necessity and coverage

indications through the prior authorization process

 Maintain effective written and verbal communication with the members and associated

professionals

 Document all case management and care coordination activities within the designated

software

 Demonstrate an ongoing understanding of Medicare benefits

 Assists with issues that may arise due to quality of care and/or adverse risk review

 Complies with health plan's internal policies and procedures

 Other duties as assigned

Professional Competencies:

 Outstanding customer service and interpersonal skills

 Excellent written and oral communication

 Provides critical attention to detail for accuracy and timeliness

 Works autonomously and effectively sets priorities

 Manages multiple tasks and remains flexible in a dynamic work environment

 Exercises sound clinical judgement, independent analysis, critical thinking skills and

knowledge of health conditions to determine best outcomes for members

 Technically comfortable working within multiple computer systems

 Demonstrates clinical knowledge and experience relative to patient care and healthcare

delivery processes.

 Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care,

and concurrent patient management.

Preferred Experience:

 Relevant clinical experience which may include acute patient care, discharge planning,

case management, utilization review, etc.

 Certification as a case manager

 One (1) year of health insurance plan experience or managed care environment

preferred.

Preferred Education and Training:

 Graduate of an accredited nursing program

Required Licensing or Certification:

 Current unencumbered RN license

Job Types: Full-time, Contract

Pay: $50.00 - $60.00 per hour

Expected hours: 40 per week

Schedule:

8 hour shift
Monday to Friday

Application Question(s):

Do you have managed care experience within a health plan?
Do you have 2 years experience with MediCaid or MediCare?
Oregon is NOT a compact state. Do you current have an active Oregon RN License?

Work Location: Remote

Toney HealthCare Consulting, LLC

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Nurse Case Manager