RN, LPN, PA, or FNP degree with valid NC license.
For RN, PA, or FNP, 3 years previous clinical nursing experience, preferably in a variety of clinical settings, or 2 years in a health insurance related industry such as Utilization Management processes, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI regulations.
If LPN, 5 years previous clinical nursing experience preferably in a variety of clinical settings, or 4 years in a health insurance related industry such as Utilization Management processes, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI regulations.
Additional Education/Experience Preferences
BSN strongly preferred.
Computer experience including Word.
Knowledge of Microsoft Windows operating system.
Demonstrated commitment to high quality service to all customers.
Knowledge of medical care patterns, regulatory and governmental rules and regulations along with medical criteria and policies related to care management.
Clinical decision making skills.
Ability to embrace and accept change.
Ability to work with an interdisciplinary team is essential.
Department Specific Job Functions/Components
Health Coaching and Interventions:
May provide health coaching and education to members based on their benefit plan.
Negotiates acceptable rate for services when appropriate.
Performs database search, telephonic screening and assessment, documentation, and evaluation of clinical information to determine eligibility for DM Programs.
Identifies, facilitates, and coordinates, when appropriate, community and social services resources to compliment the physician’s treatment plan.
Demonstrates understanding of the Case Management process by consistently adhering to member privacy and confidentiality regulations, advocating for member safety and strict adherence to ethical, legal and accreditation/regulatory standards.