Nurse Case Manager - 19265

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

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 may include, but are not limited to: Assesses members for care needs. Develops treatment plan with practitioners, providers, members and support system. Coordinates implementation of treatment. Monitors and evaluates effectiveness of case management plan and modifies as necessary. 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. Deals extensively in discharge planning as well as quality of care in an on site environment. Interfaces with Medical Directors and Physician Advisors on development of case management treatment plans. Solves provider, claims or service issues. Ensures quality member care is provided. May coordinate medical service/appointments once discharge is complete and make the necessary community resource referrals. Performs other duties assigned.

Required: RN and current professional clinical license plus 2-3 years of pertinent clinical or case management experience. Strong written, oral and interpersonal communication skills. Ability to comprehend medical policy and criteria to clearly articulate health information. 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 people skills sufficient to establish relationships with members, families, providers, etc. Good customer service orientation. Negotiation and facilitation skills. Good organizational, problem solving and decision-making skills. Knowledge of PCs and related applications such as Excel, Word, Access, etc. Certification in Case Management preferred. Some travel required.