Primary Nurse Case Admin I

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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.

• 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.

• Experience in managing complex or catastrophic health cases
• Specialty clinical experience in intensive care medicine, orthopedic, NICU / pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
• Working toward or completion of CCM / CCP / CDE certification or Advanced degree
• Knowledge of Milliman Guidelines or similar clinical guidelines
• Knowledge of medical management policies and procedures

LI-REMOTE

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HCSC Employment Statement :

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.

We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace.

Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.