RN Case Manager

NTT Data (Confidential Company) Corona , CA 92879

Posted 2 weeks ago

The Case Manager will serve as an office-based medical management resource for the business teams and will provide medical expertise to our clients' customers. This position will also serve as a liaison with Utilization and Case Management partners.



Qualifications:

  • Registered Nurse (RN) with unrestricted State license highly desired
  • BSN, CCM desirable
  • 5-10 years of broad-based clinical experience (ER, ICU, Medical-Surgical preferred)
  • 5 plus years’ experience as Claims Supervisor, Supervisor or Team Lead highly desired
  • Maintenance of professional certification through relevant continuing education
  • Working knowledge of clinical guidelines
  • Possess critical thinking skills
  • Must be able to communicate effectively with others through expression of interest, empathy, voice quality, courtesy and in written composition.
  • Must be able to exhibit professional behavior always when communicating with customers, clients, co-workers, and management.
  • Must be able to demonstrate ability to accept changing job priorities, learn new skills, and incorporate new skills into day-to-day work activities.
  • PC, keyboard skills and use of Outlook, Word, Excel, with the ability to master additional information system applications.

Duties/

Responsibilities:
Typical essential functions include but are not limited to those listed below.

  • Acting as an internal and external clinical resource for, and maintains professional relationships with, Claims, Underwriting, Administration, Client Services, Employer Group Representatives, Stop Loss and other customers
  • Monitors Pre-certification and Utilization Management based on requirements of plan documents and appropriate clinical guidelines
  • Coordinates and/or monitor the Peer Review Process when established criteria are not met
  • Provides written Precertification, Utilization Management and Peer Review determinations internally to support claim adjudication and turnaround times for compliance with internal and regulatory requirements
  • Identifies potential and actual high dollar/complex cases for internal, stop loss notification and/or case management referral
  • Monitors clinical case management program
  • Reviews and monitors Case Management reporting and case savings by vendors
  • Offers assistance and guidance to Utilization Management and Case Management vendors as required
  • Establishes and reports outcomes from Utilization Management and Case Management programs as required by management
  • Employee shall also perform such further duties as are incidental or implied from the foregoing, consistent with the background, training, and qualifications of the employee or may be reasonably delegated as being in the best interests of the organization. Employee shall devote full time to his/her employment and expend best efforts on behalf of the organization.

Work Environment / Physical Requirements

  • The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • While performing the duties of this job, the employee is regularly required to communicate by phone, email and in person with other staff members.
  • The employee must maintain a valid California Drivers’ license.
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RN Case Manager

NTT Data (Confidential Company)