Specialized Recruiting. Temporary Staffing. Managed Services. 800 876 2314


Case Manager - RN

Employment Type Permanent
Field of Work Clinical/Medical

 

Position Summary

The OrthoCare Case Manager is directly responsible to either the Senior OrthoCare Manager, Medical Management Manager, Director of Medical Services, Director of Medical Management, or Vice President of Medical Management depending upon their job location and program that they are managing, and has the administrative responsibility for the overall direction, utilization, supervision, instruction, and examination of the medical care of the member patients assigned to them.

 

Position Responsibilities

  • Responsible for ensuring the effective utilization of medical services through the application of nationally recognized medical necessity criteria
  • Responsible for all aspects of the utilization review process including precertification, concurrent and retrospective reviews for pain management services to ascertain medical justification through the application of established criteria
  • Identify quality of care issues, request medical records and refer to the Medical Director for further review as needed
  • Identify appropriate providers and facilities for the HMO membership throughout the continuum of care ensuring that the care is cost effective and of high quality
  • Receiving initial and concurrent reviews on pain management procedures to determine appropriate authorization or denial recommendations
  • Participation in training classes related to URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA and other department related training as applicable
  • Ensure that the Scope of Practice roles and responsibilities are followed
  • Perform an expected amount of 35-40 reviews in an eight hour work day
  • Perform other duties as assigned

 

Position Requirements

  • BSN; Current and active State Licensed/Registered or Certified in Nursing
  • A minimum of five (5) years' experience, at least one (1) year of which must have been Case Management, or Pre-Authorization related; Pain Management experience a plus Knowledge of the clinical criteria (e.g. Milliman (MCG), CMS, InterQual, etc.)
  • Proficiency in operating computers applications
  • Excellent interpersonal skills
  • Excellent verbal and written communications skills

 

Machine, Office Equipment, Software

  • MS Office (MS Word, Excel, and Power Point)
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