Nurse Case Mgr I/II/Sr (Job Family)

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.Performs care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Primary duties may include, but are not limited to: Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Requires BA/BS or higher in a health related field and licensure as a health professional, or certification as a care manager, or current unrestricted RN license in applicable state(s) and 3 years clinical experience or any combination of education and experience, which would provide an equivalent background. Requires knowledge of care management assessment technique, provider community, and community resources. 1 year experience in home health/discharge planning preferred. Must have strong oral, written and interpersonal communication skills, PC skills to include word processing, spreadsheet, and database applications, organizational and problem-solving skills, and decision-making skills. The following are level distinctions that are not required for posting. This level typically deals with the least complex cases and works under general guidance, having had limited or no previous managed care experience.