Nurse Case Manager - CFHP

University Health Careers; Boerne (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

University Health Careers is seeking a registered nurse in Boerne, TX to support CFHP members in obtaining necessary healthcare services efficiently. The role requires Texas RN licensure with 4+ years of nursing/acute care/quality or managed care, BSN/MSN preferred, and knowledge of InterQual criteria, DRG/ICD/CPT coding, Medicaid and NCQA standards. You will work with a multidisciplinary team to ensure proper discharge planning and coordinated care.

Qualifications

• RN license in Texas is required.
• BSN or MSN preferred; 4+ years in nursing, acute care, quality or managed care.

Responsibilities

• Oversee resource allocation, cost and quality of care for members.
• Coordinate care among providers, resources, family and members.
• Monitor benefit utilization and collaborate with multi-disciplinary team to address education and discharge needs.

Skills

InterQual screening criteria

DRG/ICD/CPT coding

Medicaid knowledge

Managed care experience

Education

RN licensure

BSN or MSN preferred

Job description

POSITION SUMMARY/RESPONSIBILITIES

Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible. Responsibilities include but are not limited to: overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members.

EDUCATION/EXPERIENCE

RN is required. BSN or Master’s degree is preferred. Minimum four (4) years nursing, acute care, quality management or managed care experience is required. Knowledge of InterQual screening criteria and coding resources (DRG, ICD and CPT) is required. Knowledge of Medicaid, community resources, alternative funding programs, Texas Health and Human Services Commission and Texas Department of Insurance HMO standards and NCQA in a managed care setting is required.

LICENSURE/CERTIFICATION

Current licensure as a Registered Nurse with the Texas State Board of Nurse Examiners is required. Current certification from an appropriate professional agency such as Case Management Society, is required.