Nurse Case Manager - CFHP PRN

University Health; San Antonio (TX); Presencial; USD 70.000 - 110.000; Jornada completa

Descripción de la vacante

University Health is seeking an experienced nurse case manager to identify and support Community First Health Plan members with complex health needs. You will evaluate services, approve care plans, and monitor outpatient care to ensure optimal outcomes in a safe, cost-effective manner.

The role requires a BSN (Master's preferred) and at least three years of acute care or managed care experience, plus knowledge of Medicaid resources and InterQual criteria. CCM certification is a plus.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Case management

Utilization management

Quality assurance

Medicaid knowledge

Educación

BSN preferred

Master’s degree preferred

Herramientas

InterQual criteria

DRG coding

ICD-9 coding

CPT coding

Descripción del empleo

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.