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Primary Nurse Case Admin I

Primary Nurse Case Admin I

Job Description

We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability, or protected veteran status.

BASIC FUNCTION:
This position is responsible for performing all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM) and is a single source of contact for members, health care personnel and all other entities involved in managing care. The Primary Nurse Coordinator performs concurrent review, discharge planning and care coordination; identifies alternate treatment programs; consults with physicians, providers, members, and other resources to evaluate options and services required to meet an individual
*s health needs; promotes quality and cost effective outcomes; and serves as liaison to physicians and members. Other functions also include episodic case management, determining member assignment of treatment, and pre-admission/post-discharge counseling for an acute condition. Establish relationship with the member through the immediate post discharge follow-up period or until all short term care needs are met. Provide education/local resource information and encourage member (self) education. Functioning in a clinical care advisory role, the Primary Nurse Coordinator assesses members for wellness education and disease management, introduces members to our website tools, educates members regarding wellness and specific conditions, and facilitates the coordination of care for identified members.

JOB REQUIREMENTS:
*Registered Nurse (RN) with current, valid, unrestricted license in state of operations
*2 years clinical practice experience of direct clinical care to the customer
*1 year experience in Condition Management or Case Management in a health insurance/managed care setting, or health care experience
*PC proficiency to include Word, Excel, Lotus Notes and database experience
*Clear and concise verbal and written communication skills
*Knowledge of UM/CM/DM activities and standardized criteria set
*Familiarity of ancillary services including HHC, SNF, Hospice, etc
*Verbal and written communication skills; analytical skills; sound clinical judgment

Job Requirements

*Experience in managing complex or catastrophic health cases
*Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
*Working toward or completion of CCM/CCP/CDE certification or Advanced degree
*Knowledge of Milliman Guidelines or similar clinical guidelines
*Knowledge of medical management policies and procedures


Job Snapshot

Employment Type Full-Time
Job Type Health Care, Nurse
Education Not Specified
Experience Not Specified
Manages Others Not Specified
Industry Insurance
Required Travel Not Specified
Job ID US-1964
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Primary Nurse Case Admin I


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