Nurse Case Manager Sr - 19221

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. Typically manages more complex cases and serves as resource to lower-leveled case managers as needed. 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 the 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 and 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 highly complex 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. Assists with development of Utilization/Care Management policies and procedures. Performs other duties assigned.

Required: RN and current professional clinical license required. At least 4-5 years of pertinent clinical or case management experience. Typically requires a minimum of two years experience in WellPoint case management. Certification in Case Management. Strong written, oral and interpersonal communication skills. Ability to comprehend medical policy and criteria to clearly articulate health information. Broad clinical knowledge base of disease processes. Strong ability to interpret and analyze medical information. Strong knowledge of case management assessment techniques and health care service providers, community organizations and state agencies. Strong understanding of appropriate member contracts and awareness of contract benefits. Strong people skills sufficient to establish relationships with members, families, providers, etc. Strong customer service orientation. Strong negotiation and facilitation skills. Ability to train and coach lower level Case Managers and team members. Ability to work on multiple complex projects. Strong organizational, problem solving and decision-making skills. Strong knowledge of PCs and related applications such as Excel, Word, Access, etc. Some travel required.