- 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.
- 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 and accurate documentation.
- Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.
- Knowledge of health insurance industry trends, technology and contractual arrangements.
- General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.
- Strong oral, written and interpersonal communication and customer service skills.
- Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.
- Strong organization and time management skills with the ability to manage workload independently.
- Ability to think critically and make decision within individual role and responsibility.
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Remote Care Management Nurse - Renton, United States - Cambia Health
Description
Care Management Nurse (Future Opportunities)Remote within WA, OR, ID, UT. Candidates outside of these states will not be considered.
Primary Job Purpose
The Care Management Nurse provides clinical care management (such as case management, disease management, and/or care coordination) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes.
Oversees a collaborative process with the member and those involved in the member's care to assess, plan, implement, coordinate, monitor and evaluate care as needed.
Please note this role is a candidate pool, and we are always looking for top talent.We do not always have open positions but we encourage you to submit your resume so you will be considered for all open roles as they become available.
General Functions and OutcomesCare Management Nurse would have a/an Associate or Bachelor's Degree in Nursing or related field and 3 years of case management, utilization management, disease management, or behavioral health case management experience or equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care
Must have at least one of the following: Certification as a case manager from the URAC-approved list of certifications; or Bachelor's degree (or higher) in a health or human services-related field (psychiatric RN or Master's degree in Behavioral Health preferred for behavioral health care management); or Registered nurse (RN) license (must have a current unrestricted RN license for medical care management)
#LI-Remote
The expected hiring range for a Care Management Nurse is $ $41.50 an hour depending on skills, experience, education, and training; relevant licensure / certifications; and performance history.
The bonus target for this position is 10%. The current full salary range for this role is $ $55.00 an hour.Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits.
In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current.
Some highlights:
* medical, dental, and vision coverage for employees and their eligible family members
* annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
* paid time off varying by role and tenure in addition to 10 company holidays
* up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
* up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
* one-time furniture and equipment allowance for employees working from home
* up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace.
All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law.
A background check is required.If you need accommodation for any part of the application process because of a medical condition or disability, please email Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.
As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic.
Please review the policy on our Careers site.
