Nurse Case Manager - CFHP PRN

University Health; Hondo (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

University Health seeks a Registered Nurse for case management within Community First Health Plan. You will identify members with specific health care needs and provide interventions to coordinate care.

You will analyze and approve health care services, monitor outpatient care planning, and ensure plans align with established criteria and plan policies. You will communicate case management plans to move members toward optimum outcomes safely and cost-effectively.

Qualifications

• Graduation from an accredited school of professional nursing is required.
• BSN preferred.
• Master’s degree 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, DRG, ICD-9 and CPT coding is 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.

Education

Graduation from an accredited school of professional nursing (required)

BSN preferred

Master’s degree preferred

Minimum three years acute care or managed care experience

Minimum one year concurrent review experience

Utilization management and/or quality assurance experience

Knowledge of Medicaid, community resources and alternate funding programs

InterQual screening criteria knowledge

DRG, ICD-9 and CPT coding knowledge

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.