Found Description
Responsibilities
- Review claims, prior auth requests, and ADT data to identify members needing case management
- Conduct clinical assessments and build individualized care plans
- Coordinate with PCPs, specialists, hospitals, and post-acute providers to ensure care execution
- Support members through complex episodes including new diagnoses and hospitalizations
- Partner with utilization management workflows on medical necessity and level of care
- Contribute to clinical protocols, escalation pathways, and internal tooling
- Maintain thorough documentation and regulatory compliance
Requirements
- Active, unrestricted RN license (multi-state compact license strongly preferred)
- 5+ years of clinical nursing experience
- Experience in case management, utilization management, care coordination, or discharge planning
- Ability to interpret claims data, prior auth criteria (MCG/InterQ...