PlayStation's Peak Health is seeking a Care Manager RN to join our health plan's medical management team. In this role, you will identify high-risk members and connect them to appropriate resources and programs, driving optimal quality and financial outcomes while improving community health status.
What You'll Do
- Participate in activities related to care management program build, implementation, oversight, and delegation.
- Perform utilization management reviews according to established criteria, clinical guidelines, and policies.
- Manage and triage member self-referrals to care management programs.
- Assist members in understanding medical benefits and connecting them with in-network providers and community resources.
- Identify barriers preventing members from meeting maximum quality of life.
- Review and evaluate Health Risk Assessment (HRA) data to help drive program and service development.
- Review member outcomes data and work with team members on performance improvement opportunities.
- Utilize NCQA standards in auditing member records as part of care management oversight.
- Investigate potential quality of care issues affecting member health or safety.
- May review medical records to ensure quality care.
- Assist in reviewing and updating activities and resources to address member needs.
- Participate in case management and quality committees.
- Assist in reviewing and updating policies to align with delegated processes.
- Assist in quarterly reporting of delegated case management processes to meet accreditation standards.
- Assist in submission of required documents during application to accrediting bodies.
What We're Looking For
- Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board, as a Registered Nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
- Three (3) years of healthcare clinical experience.
Nice to Have
- Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; currently enrolled in a BSN program with BSN completion within three (3) years of hire.
- Management of Medicare and/or Medicaid populations.
- Two (2) years Care Management experience.
Technical Stack
- Microsoft Office
- InterQual and/or Milliman Care Guidelines
Team & Environment
You will be an integral member of the health plan's medical management team, reporting to the Manager of Care Management.
Work Mode
This position is onsite.
