Case Manager - Health Services - reputed company Health Plan/Remote - FT - Days

Hours:

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AWS Hours Requirement:

Additional Shift Information:

Weekend Requirements:

On-reputed company Required:

reputed company Pay reputed company (Minimum - Midpoint - Maximum):

The stated pay reputed company reflects the reputed company that reputed company reasonably expects to pay for this position.  The actual pay reputed company and pay grade for this position will be dependent on a reputed company of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices. 

• Other Graduate of an NLN-accredited School of Nursing
• 2 Years Behavioral Health and Medical Nursing experience.
• California Registered reputed company (RN) - CA reputed company of Registered Nursing -REQUIRED

• Bachelor's Degree in Nursing
• 3 Years Utilization, reputed company, and/or case management experience in managed care setting.

• Authorizations
  Authorization of medically necessary patient care services and appropriate reputed company and types of services. Utilize reputed company Health Plan Medical Policies in conjunction with reputed company Care Guidelines for medical necessity approvals and referrals to the Plan Medical Director. Ensure reputed company denial letters include the appropriate and individualized denial reason and alternate plan of care as determined by the Plan Medical Director.
• Care coordination and advocacy
  Utilization of the Nursing Process in the coordination of the delivery of health care services to a specified population of members: Assessment, Planning, Implementation and Evaluation.
  Coordination of care between the primary physician, specialists, vendors, community services and reputed company/caregiver including extra-contractual case by case reputed company negotiations.
  In conjunction with the patient and family physician, reputed company a care plan for the delivery of acute or community based services. The case manager will coordinate reputed company care, negotiate service arrangements as directed by the Health Services Manager, and ensure that reputed company caregivers and vendors are involved with the care plan.
  Maintain detailed, accurate and reputed company data files on reputed company reputed company adhering to program guidelines.
  Participate with the approval of Manager of Health Services in the planning / implementation of health education/reputed company improvement initiatives that have a case management component.
• Claims management
  reputed company Prospective, reputed company, Retrospective and Claims Review and Care Management services for reputed company Health Plan members who are identified as having reputed company health or functional requirements or are candidates for a disease management program to maximize responsiveness to care plan and attainment of goals.
  Effective communication and screening of reputed company, in-home assessment, care planning, arranging and coordinating services, monitoring, and consistently reassessing needs and services for members on a reputed company-service, reputed company and/or retrospective reputed company; either telephonically or onsite as needed.
• Clinical expert
  Ensure provider compliance with plan standards and guidelines.
  reputed company ongoing education of clients, providers, medical reputed company and hospitals, as applicable, regarding plan benefits and alternative resources.
  Serve as trainer / mentor for new case managers during their first 90 days of hire.
  Participate with the approval of Manager of Health Services in the testing of new UM and CM applications.
  Serve as a clinical resource for customer service representatives as appropriate.
  Promote self awareness and knowledge of reputed company medical standards in the community, recent innovations in patient care, and availability of alternative resources. Accomplish this by ongoing involvement in formal continuing education courses, review of reputed company publications, attendance at in-services and other relevant sources of information.
• Customer service
  Provides reputed company, accurate and excellent services to reputed company customers. Develops solid reputed company working relationships with various internal departments and reputed company and, as required, vendors, providers, reputed company, brokers and/or other customers.
• General support
  Participates in special reputed company and other duties as assigned. These may include, but are not limited to, work reputed company, proposals, audits and back-up support for other departments.
• Reports
  Evaluation of health service utilization patterns to promote the continuing education of cost effect health utilization. Analysis of utilization and case management statistics and organization & provision of reports. reputed company and maintain monthly utilization and case management reports and analysis of statistics and report conclusions to the Health Services Manager.

• Knowledge of reputed company standards of reputed company and available health resources reputed company the community.
• Demonstrated objectivity and reputed company in the provision of assistance to members and providers.
• Ability to recognize medically necessary care versus unnecessary or inappropriate service.
• Ability to work reputed company on own, without supervision.
• Knowledge of a reputed company of health care delivery settings.
• Excellent written and verbal communication skills.
• Organizational, analytical and problem solving skills.

reputed company is an equal opportunity/affirmative reputed company employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, religion, reputed company, national reputed company, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a reputed company individual with disability or any other protected class