RN Case Manager – Complex Care & Care Coordination

Avera Health Plans Inc; United States; On-site; USD 43,000 - 64,000; Full time

Benefits offered by this job

PTO from day 1

Retirement match up to 5%

Career development mentorship

Job summary

Avera Health Plans is seeking an RN Case Manager to identify members who would benefit from complex care management and service coordination. The RN Case Manager develops and facilitates the member's plan of care in collaboration with physicians and care teams.

This role requires NCQA knowledge across commercial, marketplace, and self-funded lines, with interaction among health system stakeholders and community resources to achieve cost-effective, high-quality outcomes.

Qualifications

• RN with current license in state of practice
• 4-6 years nursing experience in acute care setting
• CCM or CM certification within 3 years preferred

Responsibilities

• Identifies cases for complex/chronic condition management and/or service coordination using claims, reports, risk stratification, utilization data, and referrals.
• Develops and executes individualized care plans aligned with NCQA standards to achieve optimal health outcomes.
• Performs utilization management activities including preauthorizations, inpatient admissions, continued stay reviews, and retro reviews.
• Manages end-to-end care for transplant patients across all phases (pre, intra, post) including authorization, case management, and network coordination.
• Interprets clinical data to support utilization management decisions and communicates findings to stakeholders across departments.
• Educates stakeholders on benefit design, network status, and claims processing for approved services.
• Directs transitions of care to network providers and coordinates services to ensure cost-effective, high-quality outcomes.
• Advocates for member health by promoting age-appropriate screenings and facilitating compliance with preventive services.
• Identifies community resources to address social determinants of health.

Skills

Care coordination

Utilization management

Case management

Clinical communication

RN licensure

Education

Registered Nurse (RN) - Board of Nursing

CCM/ABMCN within 3 years

Job description

Avera Health Plans is seeking an RN Case Manager to identify members who would benefit from complex care management and service coordination. The RN Case Manager develops and facilitates the member's plan of care in collaboration with physicians and care teams.

This role requires NCQA knowledge across commercial, marketplace, and self-funded lines, with interaction among health system stakeholders and community resources to achieve cost-effective, high-quality outcomes.