Remote Care Management Nurse (Future Opportunities) - R-5291_16-4185

$86,320 - $86,320/Yr

Cambia - Pocatello, ID

Full-time - Mid Level

Remote - Pocatello, ID

Insurance Carriers and Related Activities

About the position

The Remote Care Management Nurse role at Cambia Health is designed for Registered Nurses looking to transition from bedside care to a position that leverages their clinical expertise in a remote setting. This position focuses on providing clinical care management, including case management, disease management, and care coordination, to meet the specific healthcare needs of members while promoting quality and cost-effective outcomes. The role involves collaborating with members and their care teams to assess, plan, implement, coordinate, monitor, and evaluate care, ensuring a person-focused healthcare experience.

Responsibilities

• Conducts case management activities, including assessment, planning, implementation, coordination, monitoring, and evaluation to identify and meet member needs.
• Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, utilizing evidence-based criteria and practicing within the scope of their license.
• Collaborates with physician advisors, internal and external customers, and other departments to resolve claims, quality of care, member or provider issues, and identifies problems or needed changes, recommending resolutions and participating in quality improvement efforts.
• Serves as a resource to internal and external customers, responding to inquiries in a professional manner while protecting confidentiality of sensitive documents and issues.
• Provides consistent and accurate documentation, ensuring compliance with performance standards, corporate goals, and established timelines.
• Coordinates resources, organizes, and prioritizes assignments to meet goals and timelines.
• Monitors and evaluates the effectiveness of case management plans, gathering sufficient information to determine the plan's effectiveness and making adjustments as needed.

Requirements

• Associates or Bachelor's Degree in Nursing or related field.
• 3 years of case management, utilization management, disease management, or behavioral health case management experience.
• Equivalent combination of education and experience.
• Must have licensure or certification in a state or territory of the United States that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline.
• Must have at least one of the following: Certification as a case manager from the URAC-approved list of certifications; or Bachelor's degree (or higher) in a health or human services-related field; or Registered nurse (RN) license.

Nice-to-haves

• Knowledge of health insurance industry trends, technology, and contractual arrangements.
• Familiarity with health care documentation systems.

Benefits

• Work from home flexibility within Oregon, Washington, Idaho, or Utah.