Primary Nurse Case Admin I - UM - TX

$58,800 - $130,100/Yr

Health Care Service Corporation - Richardson, TX

Full-time - Mid Level

Remote - Richardson, TX

1,001-5,000 employees

Insurance Carriers and Related Activities

About the position

The Primary Nurse Case Admin I position at HCSC is a full-time remote role focused on Utilization Management (UM), Case Management (CM), and Disease Management (DM). The role serves as a single point of contact for members and healthcare personnel, responsible for care coordination, concurrent review, and discharge planning. The nurse coordinator will engage with members post-discharge, provide education, and facilitate access to resources to promote quality and cost-effective health outcomes.

Responsibilities

• Perform all functions of Utilization Management (UM), Case Management (CM), and Disease Management (DM).
• Serve as a single source of contact for members and healthcare personnel.
• Conduct concurrent reviews and discharge planning.
• Identify alternate treatment programs and consult with physicians and providers.
• Evaluate options and services required to meet individual health needs.
• Promote quality and cost-effective outcomes.
• Establish relationships with members during the post-discharge follow-up period.
• Provide education and local resource information to members.
• Assess members for wellness education and disease management.
• Facilitate coordination of care for identified members.

Requirements

• Registered Nurse (RN) with a current, valid, unrestricted license in the state of operations.
• 2 years of clinical practice experience providing direct clinical care.
• 1 year of experience in Condition Management or Case Management in a relevant setting.
• Proficiency in PC applications including Word, Excel, and database management.
• Clear and concise verbal and written communication skills.
• Knowledge of UM/CM/DM activities and standardized criteria.
• Familiarity with ancillary services such as HHC, SNF, and Hospice.

Nice-to-haves

• Experience in managing complex or catastrophic health cases.
• Clinical experience in Med/Surg, telemetry, etc.
• Working toward or completion of CCM/CCP/CDE certification or an advanced degree.
• Knowledge of Milliman Guidelines or similar clinical guidelines.

Benefits

• Professional development opportunities.
• Remote work flexibility.
• Inclusive workplace culture.