Case Management Coordinator - Renal​/Nephrology Focus

Summary

Care management interventions focus on improving care coordination and reducing fragmentation of services that recipients of care often experience, especially when multiple health‑care providers and different care settings are involved. Taken collectively, these interventions enhance client safety, well‑being, and quality of life while considering health‑care costs through cost‑effective recommendations. Effective care management directly and positively impacts the health‑care delivery system and supports the Triple Aim: improving health outcomes, enhancing the experience of health care, and reducing costs.

This is a remote position, working from 8:30am to 5:00pm Monday through Friday.

• Provide active care management: assess service needs, develop and coordinate action plans with members, monitor services, and implement plans, including member goals.
• Evaluate outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity for requested services and benefit exceptions.
• Ensure accurate documentation of clinical information to support medical‑necessity criteria and contract benefits.
• Provide telephonic support for members with chronic conditions, high‑risk pregnancy, or other at‑risk conditions, performing intensive assessment, providing at‑risk education, and using motivational interviewing, reflective listening, and readiness‑to‑change assessment to elicit behavior change.
• Participate in direct intervention and patient education with members and providers about health‑care delivery, network utilization, and benefit plans.
• Identify, initiate, and participate in on‑site reviews.
• Serve as member advocate through continued communication and education.
• Promote enrollment in care‑management programs and/or health and disease‑management programs.
• Provide written and telephone communication regarding requested services to health‑care providers and members.
• Perform medical or behavioral review/authorization processes and ensure coverage for appropriate services within benefit and medical‑necessity guidelines.
• Utilize allocated resources to support review determinations.
• Identify and refer to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality‑of‑care Referrals, etc.).
• Collect and input clinical information into the system for proper claims adjudication.
• Demonstrate compliance with applicable legislation and guidelines, including ERISA, NCQA, URAC, DOI (state), and DOL (federal).
• Maintain current knowledge of contracts and network status of all service providers and apply this knowledge appropriately.
• Assist with claims information, discussion, and/or resolution, referring to internal support areas to ensure proper processing of authorized or unauthorized services.

• Associate’s degree in a job‑related field.
• Two (2) years of job‑related work experience.
• Four (4) years of recent clinical experience in a defined specialty area such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, or general medicine/surgery.
• OR four (4) years of utilization review, case management, clinical, or a combination of these experiences; at least two (2) of those four years must be clinical.

• Working knowledge of word‑processing software.
• Knowledge of quality‑improvement processes and demonstrated ability with these activities.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer‑service, organizational, and presentation skills.
• Proficiency in spelling, punctuation, and grammar.
• Excellent oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Analytical or critical‑thinking skills.
• Ability to handle confidential or sensitive information with discretion.

• Microsoft Office.

• Active, unrestricted RN license from the United States and in the state of hire, OR active compact multistate unrestricted…