Primary Nurse Case Admin I - UM - TX

Health Care Service Corporation
United States, Texas, Richardson
1001 East Lookout Drive (Show on map)
Nov 16, 2024
At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary This position is responsible for performing all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM) and is a single source of contact for members, health care personnel and all other entities involved in managing care. The Primary Nurse Coordinator performs concurrent review, discharge planning and care coordination; identifies alternate treatment programs; consults with physicians, providers, members, and other resources to evaluate options and services required to meet an individual's health needs; promotes quality and cost effective outcomes; and serves as liaison to physicians and members. Other functions also include episodic case management, determining member assignment of treatment, and pre-admission/post-discharge counseling for an acute condition. Establish relationship with the member through the immediate post discharge follow-up period or until all short term care needs are met. Provide education/local resource information and encourage member (self) education. Functioning in a clinical care advisory role, the Primary Nurse Coordinator assesses members for wellness education and disease management, introduces members to our website tools, educates members regarding wellness and specific conditions, and facilitates the coordination of care for identified members. JOB REQUIREMENTS: * Registered Nurse (RN) with current, valid, unrestricted license in state of operations * 2 years clinical practice experience of direct clinical care to the customer * 1 year experience in Condition Management or Case Management in a health insurance, managed care, physician office or hospital setting. * PC proficiency to include Word, Excel, Lotus Notes and database experience * Clear and concise verbal and written communication skills * Knowledge of UM/CM/DM activities and standardized criteria set * Familiarity of ancillary services including HHC, SNF, Hospice, etc * Verbal and written communication skills; analytical skills; sound clinical judgment * Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management. Multi-state license fees will be provided by HCSC. Incumbents with other clinical licenses are not required to obtain multi-state licenses. PREFERRED JOB REQUIREMENTS: * Utilization Management experience * Quality Audit experience * Knowledge of Milliman Guidelines or similar clinical guidelines * Knowledge of medical management policies and procedures Position will focus on retrospective review audits This is a Telecommute (Remote) role: Must reside within 250 miles of the office or anywhere within the posted state. #LI-Remote INAK Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! HCSC Employment Statement: We are an Equal Opportunity Employment / Affirmative Action employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Base Pay Range$58,800.00 - $130,100.00