Case Management - Nurse, Senior

Your Role

The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members' care including clinical nurses and treating physicians. The Triage Registered Nurse Case Manager will report to the FEP Care Manager Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member's needs.

Your Knowledge and Experience

• Requires a current CA RN License
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
• Requires at least 5 years of prior experience in nursing, healthcare or related field
• Bachelor of Science in Nursing or advanced degree preferred.
• Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.
• Able to operate PC-based software programs including proficiency in Word and Excel.
• Strong clinical documentation skills, independent problem identification and resolution skills.
• Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills.
• Competent understanding of NCQA and federal regulatory requirements.
• Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable.
• Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care.
• Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.