RN Case Manager: Chronic Care & Care Coordination

Avera Health; Sioux Falls (SD); Sur place; USD 43 000 - 64 000; Plein temps

Résumé du poste

Avera Health Plans is seeking a registered nurse case manager to identify members who would benefit from complex and chronic condition management and to develop and facilitate the plan of care. You will work with physicians and health plan staff to achieve high-quality, cost-effective outcomes.

Responsibilities include care planning, utilization management, transplant case coordination, and interdepartmental collaboration to improve member outcomes and access to services.

Qualifications

• RN license required. Upon hire.
• CCM certification within 3 years or CCMCN within 3 years.
• 4–6 years of nursing experience in an acute care setting.

Responsabilités

• Identifies cases that qualify for complex/chronic condition case management and/or service coordination.
• Creates and executes care plans to meet individualized health goals.
• Performs utilization management activities including preauthorizations and reviews.
• Manages transplant cases end-to-end across all phases (pre, inpatient, post).
• Reviews and interprets clinical data to support utilization management.
• Collaborates with departments to address denials, appeals, network status, and quality of care issues.
• Educates stakeholders on benefit plan design, network status, and claims processing.
• Directs and coordinates care with network providers to ensure cost-effective outcomes.
• Advocates for members by promoting health screenings and wellness coverage.
• Identifies social determinants of health resources.

Formation

RN - Board of Nursing license

CCM/ CCMN certification within 3 years

CMNCN certification within 3 years

4-6 years nursing experience in acute care

Description du poste

Avera Health Plans is seeking a registered nurse case manager to identify members who would benefit from complex and chronic condition management and to develop and facilitate the plan of care. You will work with physicians and health plan staff to achieve high-quality, cost-effective outcomes.

Responsibilities include care planning, utilization management, transplant case coordination, and interdepartmental collaboration to improve member outcomes and access to services.