Telephonic Nurse Case Manager II

Position Title: Telephonic Nurse Case Manager II

Location - Virtual: 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.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Hours: Monday - Friday 9:00am to 5:30pm with 1-2 late evenings 11:30am to 8:00pm depending on your time zone.

*****This position will service members in different states; therefore, Multi-State Licensure will be required.

The Telephonic Nurse Case Manager II 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. Performs duties telephonically.

How you will make an impact

• Ensures member access to services appropriate to their health needs.
• 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.

Minimum Requirements

• Requires BA/BS in a health related field and minimum of 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.
• Multi-state licensure is required if this individual is providing services in multiple states.

Preferred Capabilities, Skills and Experiences

• Case Management experience is preferred.
• Certification as a Case Manager is preferred.
• Minimum 2 years’ experience in acute care setting is preferred.
• Managed Care experience is preferred.
• Ability to talk and type at the same time is preferred.
• Demonstrate critical thinking skills when interacting with members is preferred.
• Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly is preferred.
• Ability to manage, review and respond to emails/instant messages in a timely fashion is preferred.