Nurse Case Mgr Sr (Medicare) 33254

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.

Sign on bonus:$2500 

 

Work At Home  opportunity once key performance metrics are met.

 

Performs care management within the scope of licensure for members with complex and chroniccare needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Essential duties may include, but are not limited to: Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cares for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups. This position may require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and will function as preceptor for new care management staff. Also actively participates in department audit activities and performs other related duties as required. Performs other duties as assigned.Requires bachelor's degree or higher in a health related field and licensure as a health professional, or certification as a care manager, or unrestricted RN licensure in applicable states and 5 years clinical experience. Bachelor's degree in nursing, certification in appropriate product/service, clinical or care management experience appropriate to demands desired. Requires knowledge of health insurance/benefits. Requires knowledge of care management assessment technique, provider community, and community resources. Three years experience in home health/discharge planning preferred. Must have strong oral, written and interpersonal communication skills, PC skills to include word processing, spreadsheet, and database applications, organizational and problem-solving skills, and decision-making skills. The following are level distinctions that are not required for posting. This level manages the most complex cases, may participate in department audit activities, serve as preceptor for new associates and participate in or lead projects with cross-functional teams