Registered Nurse (RN) Case Manager | Avera Health Plans Medical Management

Sioux Center Health; Sioux Falls (SD); On-site; USD 43,000 - 64,000; Full time

Benefits offered by this job

PTO available day 1 for eligible hires

Up to 5% employer matching retirement

Career development guided by hands-on

Mentorship opportunities

Job summary

Avera Health Plans in the United States seeks a Registered Nurse Case Manager to identify members who would benefit from complex or chronic condition management and service coordination. You will develop and facilitate the member's care plan in collaboration with physicians, population health staff, and care teams to improve outcomes.

The role requires NCQA standards awareness, effective communication with stakeholders, and end-to-end management of transplant services when needed.

Qualifications

• Knowledge of NCQA standards and utilization guidelines.
• Ability to coordinate complex care plans.
• Strong communication with physicians and care teams.
• Ability to analyze data from claims and reports.

Responsibilities

• Identify cases for complex/chronic condition management and coordinate services.
• Create care plans aligned with NCQA standards.
• Manage preauthorizations, inpatient stays, and coverage decisions.
• Coordinate transplant-related services end to end.
• Collaborate with health plan staff and providers to optimize care.

Skills

Care coordination

Utilization management

Clinical assessment

Stakeholder communication

Education

RN license

CCM certification

CMCN certification

4-6 years nursing experience in acute care

Job description

Pay Range

The pay range for this position is listed below. Actual pay rate dependent upon experience.

Location

Avera Health Plans

Worker Type

Regular

Work Shift

Day Shift (United States of America)

Pay Range

$31.00 - $46.25

Position Highlights

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

Specialized nurse that identifies members who would benefit from complex/chronic condition case management and/or service coordination. The RN Case Manager develops and facilitates the member's plan of care. In collaboration with physicians, population health staff, employers, community organizations, hospital-based case managers/utilization review staff, clinic-based care coordinators/preauthorization staff, and Insurance Division staff, the RN Case Manager encourages the best possible outcome in the most cost effective manner in accordance with standards set forth by National Committee for Quality Assurance (NCQA). The RN Case Manager will need to be knowledgeable in various aspects of all health plan lines of business, inclusive of commercial, marketplace, and self-funded clients. The position requires interaction with health system stakeholders, key opinion leaders, vendors, delegated entities, healthcare providers, policy makers, and accreditation and government organizations.

What You Will Do

• Identifies cases that qualify for complex/chronic condition case management and/or service coordination, based on, but not limited to, the evaluation of the following data: claims, hospital reports, risk stratification, utilization management, pharmacy reports, and referrals from internal health plan staff, clinic staff, hospital discharge planners, members and providers.
• Creates and executes unique, care plans that ensure the best possible individualized health care goals for the chronic and/or complex member are met in accordance with NCQA assessment standards and requirements.
• Performs utilization management activities of selected services, including preauthorizations, inpatient admissions, continued stay reviews and retro reviews using established medical guidelines, clinical information and clinical education to determine medical appropriateness for coverage.
• Performs end to end management and authorization of all transplant members, in all phases of transplant (pre, inpatient, post). This includes authorization requests, case management services, claims inquiries, and network steerage.
• Reviews and interprets key clinical and operational data in order to provide feedback and assist with the utilization management of healthcare services.
• Effectively communicate and collaborate with other departments within the health plan including, but not limited to, clinical denials, appeals, network determination, and quality of care issues.
• Understands and educates key stakeholders on benefit plan design, network status, and appropriate claims processing for approved services.
• Directs and transitions care to network providers and coordinates service to ensure cost-effective, high-quality outcomes.
• Advocates for member's health by identifying age appropriate health screening(s), advising of wellness coverage benefits and facilitating member compliance with recommended screenings.
• Researches and identifies community resources to assist in addressing all facets of social determinants of health.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, Or Work Experience

• Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire and
• Certified Case Manager (CCM) - Commission for Case Manager Certification (CCMC) within 3 Years or
• Certified Managed Care Nurse (CMCN) - American Board of Managed Care Nurses (ABMCN) within 3 Years
• 4-6 years Nursing experience in acute care setting

Preferred Education, License/Certification, Or Work Experience

• Case management, disease management, care coordination or equivalent

Expectations and Standards

• Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera’s values of compassion, hospitality, and stewardship.
• Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement
• Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to [e-mail].