RN-Health Plan Case Manager

University of Colorado - School of Medicine
Case Manager
The Health Plan Case Manager is part of the team that provides medical management services for a large employee health plan. Position accountabilities include but not limited to utilization management, case management, program design and oversight. This position will also be collaborating with other departmental leaders to integrate principles of population health, medical management, and data analytics to establish goals for delivery of high quality cost affective health care.
The Health Plan Care Manager will be responsible for the following:
-Supervises staff to ensure compliance with state mandated regulatory requirements related to utilization management functions.
-Monitors inpatient hospital length of stay and coordinates discharge care if needed for members admitted to both in and out of network facilities.
-Case management for members where care coordination may improve quality of care and potentially provide cost containment for both the member and the health plan.
-Medical management program oversight includes but is not limited to:
+ Establish and maintain policies and procedures
+ Coordinate Medical Management Committee meeting
+ Works with Medical Director and other department leaders to establish and evaluate program goals on an annual basis
+ Undergo a yearly utilization management NCQA delegation audit if required
Position reports to Director of Population Health and Health Plan Medical Director.
The RN-Health Plan Case Manager supervises utilization management staff who are responsible for processing prior authorizations, referrals, denials and case management activities.
Qualifications:
Required Knowledge, Skills and Abilities:
Ability to interpret and apply medical necessity and length of stay criteria as part of a prior authorization process or concurrent inpatient hospitalization review.
Functions as a liaison between providers, members, and health care vendors to resolve issues or concerns related to care coordination, authorizations or payment for care.
Understanding of and compliance with state mandated requirements related to utilization management determinations (e.g. turnaround times and notification to member and provider).
Experienced in data reporting and higher level analytics used to evaluate effectiveness and identify areas for improvement in the medical management program.
Strong communication skills.
Minimum Qualifications:
-RN-BSN (Licensed Registered Nurse in State of Colorado)
-3-5 year's experience in Patient Care Management (Case Management, Patient Centered Medical Home, Population Health, Health Care Navigator, Medical Management)
Preferred Qualifications:
RN-MSN (Licensed Registered Nurse in State of Colorado)
Salary and Benefits:
Salary is commensurate with skills and experience. The University of Colorado offers a full benefits package. Information on University benefits programs, including eligibility, is located atEmployee Services.
The University of Colorado Denver is dedicated to ensuring a safe and secure environment for our faculty, staff, students and visitors. To assist in achieving that goal, we conduct background investigations for all prospective employees.
The University of Colorado strongly supports the principle of diversity. We encourage applications from women, ethnic minorities, persons with disabilities and all veterans. The University of Colorado is committed to diversity and equality in education and employment.
The Immigration Reform and Control Act requires that verification of employment eligibility be documented for all new employees by the end of the third day of work. Alternative formats of this ad are available upon request for persons with disabilities.
Special Instructions to Applicants:
Application Materials Required:Cover Letter, Resume/CV, List of References
Application Materials Instructions:
Applications are accepted electronically atCU Careers, refer to requisition ID:05859
When applying, applicants must include:
+ A letter of application which specifically addresses the job requirements and outlines qualifications
+ A current Resume/CV
+ The names, addresses, daytime telephone numbers and e-mail addresses for three professional references, either attached to your resume/CV or uploaded as a separate document
Please be advised that the University does check references as part of the employment process.
Please do not submit any of your application material (via email) to the job posting contact. 849a25a5909e4c32885069f7acb8ce2c

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