Nurse Case Manager Lead

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

The Telephonic Nurse Case Manager Lead is responsible for care management within the scope of licensure for members with complex and chronic care 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.

Performs duties telephonically or on-site such as at hospitals for discharge planning.

- 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.

- 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 cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.

- May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.

- Participates in audit activities and assists supervisor with management of day-to-day activities, such as monitoring and prioritizing workflow, delivering constructive coaching and feedback, and developing associated corrective action plans at direction of the manager.

- Develops training materials, completes quality audits, performs process evaluations, and tests and monitors systems/process enhancements.

- Requires a BA/BS in a health related field and 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.

- Current, unrestricted RN license in applicable state(s) required.

- Case manager certification required within 3 years of starting in this role.