Nurse Case Manager II

• Manage care for members with complex and chronic care needs within the scope of licensure
• Assess members and develop individualized care management plans
• Implement care plans by facilitating authorizations and referrals
• Coordinate internal and external resources to meet identified member needs
• Monitor and evaluate care plan effectiveness and modify plans as necessary
• Interface with Medical Directors and Physician Advisors on treatment plans
• Negotiate reimbursement rates when applicable
• Help resolve provider, claims, or service issues
• Assist with development of utilization and care management policies and procedures
• Perform duties telephonically
• Ensure member access to services appropriate to their health needs

• BA/BS in a health-related field and minimum of 5 years of clinical experience, or an equivalent combination of education and experience
• Current, unrestricted RN license in applicable state(s) required
• Multi-state licensure required when providing services in multiple states
• Case management experience preferred
• Case Manager certification preferred
• Minimum 2 years’ experience in an acute care setting preferred
• Managed care experience preferred
• Ability to talk and type simultaneously preferred
• Critical thinking skills when interacting with members preferred
• Experience with Microsoft Office and/or ability to learn new computer programs, systems, and software quickly preferred
• Ability to manage, review, and respond to emails/instant messages promptly preferred
• Ability to work Monday–Friday, 9:00 a.m.–5:30 p.m., with 1–2 late evenings from 11:30 a.m.–8:00 p.m., depending on time zone
• COVID-19 and Influenza vaccination required for certain patient/member-facing roles unless an acceptable explanation is provided

Demonstrates expertise in care management for members with complex health needs, including the development and implementation of individualized care plans, coordination of resources, and effective communication with medical professionals. Holds a current RN license and possesses strong critical thinking and case management skills.

• RN License
• Case Management Experience
• Care Plan Development
• Managed Care Experience
• Critical Thinking Skills

• Care Management
• Individualized Care Plans
• Utilization Management
• Reimbursement Negotiation
• Acute Care Experience
• Telephonic Communication
• Microsoft Office Proficiency
• Email Management

• Interpersonal Communication
• Problem Solving
• Adaptability

• Case Manager Certification

• Chronic Care Management
• Health Needs Assessment
• Multi-State Licensure
• Provider Relations
• Utilization Policies