Nurse Case Manager - CFHP

University Health Careers; Hondo (TX); On-site; USD 75,000 - 105,000; Full time

Job summary

Community First Health Plan (CFHP) seeks an experienced registered nurse to oversee care coordination and ensure access to services for members in Texas. The role emphasizes efficient resource allocation, quality of care, and collaboration with PCPs, family, and community resources.

Requirements include an active Texas RN license, BSN or Master's preferred, and at least four years in nursing or managed care.

Qualifications

• RN with current Texas licensure
• BSN or Master’s degree preferred
• Minimum four years nursing, acute care, quality management or managed care experience
• Knowledge of InterQual screening criteria and coding resources (DRG, ICD and CPT)
• Knowledge of Medicaid, community resources, Texas HHSC and TX Department of Insurance HMO standards and NCQA in a managed care setting

Responsibilities

• Oversee resource allocation, cost and quality of care for members.
• Coordinate care between the PCP, community resources, family and member.
• Coordinate care across the health care continuum while monitoring and managing benefit utilization.
• Collaborate with multi-disciplinary health care team members in identifying the educational and discharge needs of members.

Skills

Care coordination

Medicaid knowledge

Texas HHSC standards

NCQA in managed care

4+ years nursing/acute care/quality管理/

Education

BSN degree

Master’s degree

Tools

InterQual criteria knowledge

DRG coding

ICD coding

CPT coding

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.