Care Manager RN (Delaware

JOB SUMMARY

This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction.

Responds to customer inquiries and offers interventions and/or alternatives.

• Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.
• Function in accordance with applicable state, federal laws and regulatory compliance.
• Promote quality and efficiency in the delivery of care management services.
• Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.
• Practice within the scope of ethical principles.
• Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
• Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member.
• Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.
• Other duties as assigned or requested.

• Bachelor's Degree in Nursing or relevant experience and/or education as determined by the company in lieu of bachelor's degree

• Master's Degree in Nursing

• 3 years of related, progressive clinical experience in the area of specialization
• Experience in a Clinical Setting

• Experience in UM/CM/QA/Managed Care

• United States Registered Nurse (RN) license
• Delaware RN license must be obtained within the first 6 months of employment, unless the home state license is part of the compact

• Certification in Utilization Management or a related field

• Working knowledge of pertinent regulatory and compliance guidelines and medical policies
• Ability to multi task and perform in a fast paced and often intense environment
• Excellent written and verbal communication skills
• Ability to analyze data, measure outcomes, and develop action plans
• Be enthusiastic, innovative, and flexible
• Be a team player who possesses strong analytical and organizational skills
• Demonstrated ability to prioritize work demands and meet deadlines
• Excellent computer and software knowledge and skills

None

0% - 25%

Position Type

Office-based

Teaches / trains others regularly – Occasionally

Travel regularly from the office to various work sites or from site-to-site – Rarely

Works primarily out-of-the office selling products/services (sales employees) – Never

Physical work site required – Yes

Lifting: up to 10 pounds – Constantly

Lifting: 10 to 25 pounds – Occasionally

Lifting: 25 to 50 pounds – Rarely

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement:
This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must…