CASE MANAGER, RN-15877

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.

In this position the Case Manager is responsible for working with members and providers to assess, facilitate, plan and coordinate the delivery of care across the continuum for members with potential risk for high cost and high utilization. Essential duties include, but are not limited to: Assesses the medical needs and implement a case management program (facilitating, planning and advocating health needs) for targeted members on an individual basis; and develops treatment plan with practitioners, providers, members and support system. Coordinates the implementation of treatment. Monitors all aspects of the members' medical needs from precertification through discharge planning, as well as the medical necessity of home health care, skilled nursing or hospice services. Comprehends complex policies and medical criteria as it pertains to member care from pre-admission through discharge. Interfaces with Medical Directors and Physician advisors on development of case management reatment plans.  Solves provider, claims or service issues.  Ensures quality member care is provided, identifies treatment delays, and avoidable delays as well as alternative treatment programs or specialty care if mutually beneficial to the member and overall cost of care. May coordinate for medical service/appointments once discharge is complete and make the necessary community resource referrals. Performs other duties assigned.



Qualified candidates will have an active, unrestricted Indiana RN license and 3+ years of recent, pertinent clinical or case management experience. Certification in Case Management preferred. Clinical knowledge base of disease processes.  Ability to interpret and analyze medical information. Knowledge of case management assessment techniques.  Knowledge of health care service providers, community organizations and state agencies.  Good understanding of appropriate member contracts and awareness of contract benefits.  Good customer service orientation and people skills sufficient to establish relationships with members, families, providers, etc.  Negotiation and facilitation skills.  Strong written, oral and interpersonal communication skills required. Ability to comprehend medical policy and criteria to clearly articulate health information is required.  Strong analytical, problem-solving and computer skills in Excel, Word, Access, etc. Some travel required. Must be available for and willing to work some evening hours.