RN Case Manager

Duration: 06 Months.

Active, unrestricted, and good standing RN license in the state of Florida.

The RN Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness.

Skills: Must Have:

• Utilization Management Prior Authorization Review experience preferred.
• Bi-Lingual Spanish/ English required.

Experience:

• Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration.
• Using clinical tools and information/data review, conducts an evaluation of member's need and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
• Applies clinical judgement to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues.
• Assessments consider information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.
• Reviews prior claims to address potential impact on current case management and eligibility.
• Assessments include the member’s level of work capacity and related restrictions/limitations.
• Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality.
• Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents case at case conferences for multidisciplinary focus to benefit overall claim management.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

Professional Qualification:    

• Active RN License required.
• Associate degree Required and BSN preferred.
• 2+ years of clinical experience 

Experience Required: 01-03 Years.

Shift: Normal hours are Monday through Friday 8:00am – 4:30pm EST. Employees can flex their 8-hour shift between 8:00am-6:00pm. Candidates must reside in Miami Dade/Monroe and be willing and able to travel 50% of their time.