Job Description:

• working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients
• application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
• applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues
• assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality
• consults with supervisor and others in overcoming barriers in meeting goals and objectives
• presents cases at case conferences for multidisciplinary focus to benefit overall claim management
• utilizes case management processes in compliance with regulatory and company policies and procedures
• utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations
• identifies and escalates member’s needs appropriately following set guidelines and protocols
• need to actively reach out to members to collaborate/guide their care
• perform medical necessity reviews.

Requirements:

• 5+ years’ experience as a Registered Nurse
• 1+ years’ experience documenting electronically using a keyboard
• 1+ years’ current or previous experience in Oncology
• A RN who resides in a compact state is required to have an active multistate license through the Nurse Licensure Compact (NLC)
• Nurses residing in non‑compact states must hold an individual, state‑specific RN license for each state they support
• 1+ years’ experience in Utilization Review
• CCM and/or other URAC recognized accreditation preferred
• 1+ years’ experience with MCG, NCCN and/or Lexicomp
• Bilingual in Spanish preferred.
• Bachelor's Degree Education Diploma or Associates Degree in Nursing required.

Benefits:

• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility