Care Manager RN - UM (Full-Time) Weekends (Remote

Job Title

This is a full-time REMOTE position requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

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.
• Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
• 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

Required:

None

Preferred:
Bachelor's Degree in Nursing

Required:

3 years of related, progressive clinical experience in the area of specialization;
Experience in a clinical setting

Preferred: 3 years RN experience; RN Case Management, Care Management;
Experience in UM/CM/QA/Managed Care;
Experience with acute inpatient and post-acute;
Experience with skilled nursing, inpatient Rehab

Required:

Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where clinical care is being provided.

Preferred:
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

Travel Requirement: 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:
Does Not Apply

Works primarily out-of-the office selling products/services (sales employees):
Does Not Apply

Physical work site required:
Yes

Lifting: up to 10 pounds:
Constantly

Lifting: 10 to 25 pounds:
Occasionally

Lifting: 25 to 50 pounds:
Rarely, Occasionally

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

Pay Range Minimum: $68,400.00

Pay Range Maximum: $