Nurse Case Manager - CFHP

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

Job summary

Community First Health Plan in San Antonio, TX seeks a Registered Nurse to serve as a Care Manager, coordinating care across the health care continuum to improve outcomes and access to services. Required RN licensure in Texas with 4+ years in nursing or managed care; BSN or Master’s preferred.

Knowledge of InterQual criteria and DRG/ICD/CPT coding, Medicaid/HMO standards, and NCQA in managed care is essential.

Qualifications

• RN licensure in Texas is required.
• BSN or Master's degree preferred; four years nursing/acute care/managed care experience required.
• Knowledge of InterQual criteria and DRG/ICD/CPT coding.
• Knowledge of Medicaid, Texas HHSC, Texas D.I. HMO standards and NCQA in a managed care setting.

Responsibilities

• Oversee the allocation of resources, cost and quality of health care for CFHP 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 to identify educational and discharge needs.

Skills

InterQual criteria knowledge

DRG/ICD/CPT coding knowledge

Medicaid/HMO/NCQA knowledge

Care coordination experience

Education

BSN (preferred)

Master's degree (preferred)

RN licensure (Texas)

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, alternate 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.