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.
This position is responsible for supervising and monitoring the Care Coordination staff in the evaluation and review of cases against established criteria for acceptance into Utilization Management/Case Management services, the case management program, and review of services (both services are managed within the scope of the members’ benefit plan); providing feedback for ongoing Departmental QI activities; interfacing and working with staff, peers, managers, physicians, account management, and the Full Service Unit’s in process improvement and delivery of effective customer service; and serving as a liaison for internal and external customers regarding the Medical Management processes.
*Registered Nurse (RN), with current, unrestricted license to practice in state of operations
*Registered Nurse (RN) with Bachelor Degree and 4 years clinical experience OR
combination of education and experience.
*Case Management Certification within 3 years of obtaining position.
*4 years experience in clinical nursing and utilization review, including 1 year in a managed care environment.
*Knowledge of managed care program policies and procedures.
*Knowledge of managed care and insurance industry.
*Verbal, written, and interpersonal communication skills.
*PC proficiency to include Word, Excel, PowerPoint, and Access.
*Analytical skills and sound clinical judgment.