Hybrid Care Manager, RN

at WVU Medicine

• Job title: Care Manager, RN
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: Not specified
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Morgantown, United States

About the role

• Care Manager RN connecting high risk members with resources for optimal outcomes at Peak Health. Collaborating on care management and quality improvement within the health plan's medical management team.

Responsibilities

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Perform utilization management reviews as needed according to accepted and established criteria, as well as other clinical guidelines and policies.
• Manage and triage member self-referrals to care management programs.
• Assist members in understanding their available medical benefits and connecting them with in-network providers and community resources.
• Identify barriers preventing the member from meeting maximum quality of life.
• Review and Evaluate Health Risk Assessment (HRA) data to help drive development of programs and services geared toward member needs.
• Review and Evaluate member outcomes data and work with other team members on performance improvement opportunities.
• Utilizing NCQA standards in auditing processes of member records as part of care management oversight processes.
• Investigating potential quality of care issues that may affect the quality or safety of the health of members.
• May review medical records and other documentation to ensure quality care.
• Assist in reviewing and updating activities and resources to address member needs.
• Participate in case management and quality committees.
• Assist in reviewing and updating policies and procedures to align with delegated processes.
• Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
• Assist in submission of required documents/policies during application process to accrediting body.

Requirements

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Three (3) years of healthcare clinical experience.
• Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
• Management of Medicare and/or Medicaid populations.
• Two (2) years Care Management experience.

Benefits

• Standard office environment