RN Case Manager

Job Summary:
Works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. UM is rarely ever member-facing, will probably not work BH.

Knowledge/Skills/Abilities:
• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts inpatient reviews to determine financial responsibility for the company and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Care Model.
• Adheres to UM policies and procedures.
• Occasional travel to other offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

Required Education:
Graduate from an Accredited School of Nursing.

Required Experience:
3+ years hospital acute care/medical experience.

Required License, Certification, Association:
Active, unrestricted State Registered Nursing (RN) license in good standing in the state of Nevada.

Company DescriptionSince our founding in 2005, MedNational has grown into a full-service Healthcare Human Capital Solutions Organization. We are proud to deliver our traditional permanent placement and contract service opportunities.

MedNational professionals experience career opportunities in the following niche areas:
• Hospitals
• Physicians’ offices
• Nursing care facilities
• Home healthcare services
• Government agencies
• Educational services
• Support services
• Schools
• Community centers
• Urgent care centers
• Offices

Today, we conduct business in all corners of North America, and continue to be laser focused on our mission. We deliver our clients with career oriented and quality-focused health care professionals while enriching the lives of these professionals during their period of transition to a new challenge and opportunity.