Clinical Nurse Specialist

Description One of the nation's largest health insurers within the managed care industry currently has an exciting career opportunity for a Clinical Nurse Specialist / Case Manager/Care Coordinator II for a Fresno, CA area. This is a GREAT opportunity to work for a dynamic company which encourages career growth and acts as a continual 'mentor'.
Responsibilities: ' Participates in programs to identify members at risk who are appropriate for case management services. ' Reviews, screens cases for possible case management services. ' Expedites access to appropriate care for members with urgent or immediate needs using expedited review process. ' Acquires clinical records, guidelines, policies, EOC, Benefit Policy & coding. ' Assesses the member's current status, resource utilization, past/ present treatment plan & srvcs; prognosis & provider options. ' Develops plan of care based upon assessment with goals/interventions to meet member's needs. ' Works with the member/family, provider(s), & other members of the health care team to develop a plan of care that enhances the clinical outcome while maximizing the member's benefits. ' Performs evaluation in multiple environments. ' Closes cases according to the defined case closure procedure in a timely manner, and in accordance with guidelines established. ' Identifies potential reinsurance cases and notifies the appropriate department according to policy and procedure. ' Identifies cases needing Medical Director review or input. Presents cases to Medical Director for potential review or determinations when needed. ' Refers potentially inappropriate resource utilization or quality related concerns to Medical Directors. ' Performs prospective, concurrent and retrospective reviews and first level determination approvals for assigned members, as appropriate, or refers reviews to appropriate associate. ' Utilizes considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines & benefit plans to complete reviews and determinations within required turnaround times and regulatory requirements. ' Maintains confidentiality of all PHI
Education: Bachelor's degree preferred for nursing graduates.
Certification/License: Valid State of California Registered Nurse license. Case Management certification preferred.
Experience: At least 3 years of clinical experience required 1 -3 years Case Management experience required. Health Plan experience preferred.
Knowledge, Skills & Abilities: Strong knowledge of NCQA, federal and state regulations/requirements. Demonstrated ability for assessment, evaluation and interpretation of medical information, and care planning. Possess a high level of understanding of community resources, treatment options, home health, funding options and special programs. Extensive knowledge of the management of chronic conditions. Experience using standardized clinical guidelines required. Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project.
This is a full-time/contract opportunity from Monday through Friday, from 8:00am - 5:00pm.
This opportunity offers very competitive compensation, great work environment, work-life balance, as well as excellent benefits package (e.g. 401(K) savings plan, income replacement, medical/vision/dental /life/disability insurance, paid time off program, online educational programs, tuition reimbursement, and student loan repayment program) and other perks.
For immediate and confidential consideration please contact me at 818-716-6330, or forward your resume to [Click Here to Email Your Resumé]
If you have any friends that could be interested in this position, please forward my contact information to them. Your assistance would be greatly appreciated.