Nurse Case Manager CFHP PRN

University Health; Boerne (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

University Health in Texas seeks an experienced registered nurse to lead case management for Community First Health Plan members with complex health needs.

The role involves assessing care requirements, coordinating services, approving outpatient plans, and guiding members toward safe, cost-effective outcomes within plan policies.

Required RN licensure in Texas, with BSN preferred and 3+ years in acute care or managed care; CCM certification preferred.

Qualifications

• Graduation from an accredited school of professional nursing; BSN preferred.
• Minimum three years’ acute care or managed care experience.
• Minimum one year of concurrent review experience.
• Experience in utilization management or quality assurance.
• Knowledge of Medicaid, community resources, and alternate funding programs preferred.
• Knowledge of InterQual screening criteria, DRG, ICD-9, and CPT coding preferred.

Responsibilities

• Identifies Community First Health Plan members with specific health care needs and provides case management interventions.
• Analyzes, approves health care services and monitors outpatient care planning for Community First Health Plans members based on established criteria, plan policies and procedures.
• Formulates and communicates case management plans that efficiently utilize health care services to move the member along the continuum of care towards optimum outcomes in the safest, most cost effective manner.

Skills

Case management

Utilization management

Quality assurance

Medicaid knowledge

InterQual criteria

Education

BSN (Bachelor of Science in Nursing)

Master's degree preferred

Job description

POSITION SUMMARY/RESPONSIBILITIES

Identifies Community First Health Plan members with specific health care needs and provides case management interventions. Analyzes, approves health care services and monitors outpatient care planning for Community First Health Plans members based on established criteria, plan policies and procedures. Formulates and communicates case management plans that efficiently utilize health care services to move the member along the continuum of care towards optimum outcomes in the safest, most cost effective manner.

EDUCATION/EXPERIENCE

Graduation from an accredited school of professional nursing is required, BSN preferred. Master’s degree is preferred. Minimum three years’ acute care experience or managed care experience is required. Minimum one-year of concurrent review experience is required. Candidate must have utilization management and/or quality assurance experience. Basic knowledge of Medicaid, community resources and alternate funding programs is desired. Knowledge of InterQual screening criteria as well as DRG, ICD-9 and CPT coding is preferred.

LICENSURE/CERTIFICATION

Current Registered Nurse license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) designation is preferred.