- 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
