Case Management - Nurse, Senior (RETA Trust)

Your Role

The Case Management team performs and case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs.. The Case Management Nurse, Senior will report to the Manager, Care Management. In this role you will determine, develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of member inquiry, triage hub, chronic conditions, poly-pharmacy, and voluntary member health assessment, in addition to indication of multiple monthly ER visits. The RN in this role will be assisting members of the Catholic Diocese. The Care Management Nurse-Senior empowers members to take an active role in their healthcare by educating them on the benefits of their health plan, sharing resources, and providing high-quality options for care. Our nurses primarily work from home but travel expectations for in person meetings with clergy members up to a few trips per month that may be outside of California.

Your Knowledge and Experience

• Requires a current unrestricted CA RN License.
• Other assigned states are Oregon, Nevada, and Idaho. Must maintain active, unrestricted licensing in those states or the ability to obtain required licensure within 90 days of hire.
• Requires a valid California Driver's License with Proof of Insurance
• Bachelor of Science in Nursing or advanced degree preferred.
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
• Requires at least 5 years of prior experience in nursing, healthcare or related field
• At least 3 years of managed care experience preferred
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
• Extensive knowledge of evidence based clinical practice guidelines particularly for chronic conditions.
• Incorporates professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care.
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets preferred, Care Gaps
• Able to operate PC-based software programs including proficiency in Microsoft Office 365 applications including Word, Excel, Outlook, PowerPoint and Teams.