RN Case Manager: Complex Care & Coordination

Avera Health Plans Inc; Sioux Falls (SD); On-site; USD 43,000 - 63,000; Full time

Benefits offered by this job

PTO from day 1

Employer matching retirement plan (up"

Job summary

Avera Health Plans in Sioux Falls, SD is seeking an experienced RN Case Manager to identify members who would benefit from complex and chronic condition management and to develop individualized care plans in collaboration with a multidisciplinary team.

The role involves end-to-end management and authorization for transplant members, coordinating with physicians, population health staff, and insurance division staff to ensure quality and cost-effective care in line with NCQA standards.

Qualifications

• RN license in state of practice.
• CCM certification within 3 years of hire.
• CMCN certification within 3 years of hire.
• 4–6 years nursing experience in acute care setting.

Responsibilities

• Identify cases qualifying for complex/chronic condition management and/or service coordination based on clinical data.
• Create and execute care plans for chronic/complex members.
• Perform utilization management activities including preauthorizations and reviews.
• Manage transplant member care across all phases (pre, inpatient, post).
• Review data to support utilization management and quality of care.
• Coordinate with departments on denials, appeals, network status, and claims.
• Direct transitions of care to network providers and ensure cost-effective outcomes.
• Advocate for member health and assist with screenings and social determinants of health resources.

Education

RN License

Certified Case Manager (CCM)

Certified Managed Care Nurse (CMCN)

Job description

Avera Health Plans in Sioux Falls, SD is seeking an experienced RN Case Manager to identify members who would benefit from complex and chronic condition management and to develop individualized care plans in collaboration with a multidisciplinary team.

The role involves end-to-end management and authorization for transplant members, coordinating with physicians, population health staff, and insurance division staff to ensure quality and cost-effective care in line with NCQA standards.