RN Case Manager Job Oregon area,Wisconsin USA,Nursing

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.

Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary

The RN Case Manager performs case management within the boundaries of accreditation organization standards to ensure appropriate care is delivered timely and within the appropriate setting for Moda members. Interacts with the member, family, and care providers to develop, coordinate, and monitor the member’s treatment plan. This is a FT WFHposition.

Salary range $71,990.85 - $89,988.57 Annually (depending on experience).
* This role may be classified as hourly (non-exempt) depending on the applicant's location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits:

Medical, Dental, Vision, Pharmacy, Life, & Disability
401K
- Matching
FSA
Employee Assistance Program
PTO and Company Paid Holidays

Primary Functions:

Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.

Assessment: collection of in-depth information about a member’s situation and functioning to identify individual needs.

Planning: identification of specific objectives, goals, and actions designed to meet the member’s needs as identified in the assessment.

Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan.

Coordination: organization, securing, integrating, and modifying resources.

Monitoring: gathering sufficient information to determine the plan’s effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.

Consults with physician advisors to ensure clinically appropriate determinations.

Serves as a resource to internal and external customers.

Applies clinical expertise and judgment to ensure compliance with medical policy and criteria of for accepted standards of care while performing Utilization Review and Service Authorizations for members of all books of business.

Collaborates with other departments to resolve claims, quality of care, member, or provider issues.

Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.

Responds in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.

Provides consistent, accurate and timely documentation.

Plans, organizes, and prioritizes assignments to comply with performance standards, corporate goals, and established timelines

Perform other duties and responsibilities as assigned.

Required Skills, Experience &

Education:

Graduate of accredited school of nursing; two, three or four-year…