Care Manager RN - UM (Full-Time) Weekends (Remote)

This is a full-time REMOTE position requiring weekend availability (Saturday and Sunday) in addition to three weekdays. This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

Responsibilities

Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager's professional discipline; Function in accordance with applicable state, federal laws and regulatory compliance; Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies; Promote quality and efficiency in the delivery of care management services; Respect the member's right to privacy, sharing only information relevant to the member's care and within the framework of applicable laws; Practice within the scope of ethical principles; Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions; Employ collaborative interventions which focus, facilitate, and maximize the member's health care outcomes. Is familiar with the various care options and provider resources available to the member; Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships; Develop and sustain positive working relationships with internal and external customers; Utilize outcomes data to improve ongoing care management services; Other duties as assigned or requested

Requirements

3 years of related, progressive clinical experience in the area of specialization; Experience in a clinical setting; Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC); Additional specific state licensure(s) may be required depending on where clinical care is being provided; Working knowledge of pertinent regulatory and compliance guidelines and medical policies; Ability to multi task and perform in a fast paced and often intense environment; Excellent written and verbal communication skills; Ability to analyze data, measure outcomes, and develop action plans; Be enthusiastic, innovative, and flexible; Be a team player who possesses strong analytical and organizational skills; Demonstrated ability to prioritize work demands and meet deadlines; Excellent computer and software knowledge and skills; Weekend availability (Saturday and Sunday) in addition to three weekdays; Travel Requirement: 0% - 25%

Nice to have

Bachelor's Degree in Nursing; 3 years RN experience; RN Case Management, Care Management; Experience in UM/CM/QA/Managed Care; Experience with acute inpatient and post-acute; Experience with skilled nursing, inpatient Rehab; Certification in Utilization Management or a related field