Nurse Case Manager

Clinical Evaluation and Review

•   Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)

•   Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.

•   Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards

•   Provide notifications to member and/or provider, according to regulatory requirements.

•   Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.

•   May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines

Collaboration and Documentation

•   Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work

•   Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information

•   Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.

Hiring Requirements

•   RN with 3 years of clinical experience or LPN with 5 years of clinical experience.

•   For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.

•   Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.