Responsibilities
- Manage health plan consumer/beneficiaries across the health care continuum to achieve optimal clinical, financial, operational outcomes
- Work collaboratively with both internal and external customers in assisting health plan consumer/beneficiaries’ providers with issues related to prior authorization utilization management, and/or case management
- Perform transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination
- Evaluate the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiaries’ outcomes
- Provide ongoing education to internal and external stakeholders that play a critical role in the continuum of care model. Training topics consist of population health management, evidence-based practices, and all other topics that impact medical management functions
- Ensure quality of service and consistent documentation
Basic Qualifications
*Must Reside in Pacfic Time or Mountain Time Zone
- Active Registered Nurse (R.N.) licensure
- 5+ years of Clinical Experience
- Utilization, Case, or prior Authorization Management Experience
- A Bachelor’s Degree or equivalent Experience
Preferred Qualifications
- Certified Case Manager (CCM)
- MCG Certification(s)
- RN-BC Registered Nurse Case Manager
- Certification in Managed Care Nursing (CMCN)
- Basic Life Support (BLS) certification