Nurse - Case Manager - Insurance TPA
Posted on :
27-04-2024
Employer Active
1 Vacancy
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Job Description
Req ID : 2425714
- Uses clinical knowledge to assess diagnosis and treatment plans and goals and identifies gaps in care or risks for readmission or complications.
- Manages/coordinates an active volume of cases by providing information, navigation and coordination to customers worldwide.
- Works with a multicultural population and is constantly aware of the cultural differences among that population.
- Establishes patient centric goals and interventions to meet the member’s needs.
- Interfaces with the member, family members/caregivers, and the healthcare team, as well as internal matrix partners.
- Balances business needs with patient advocacy.
- Assesses member’s health status and treatment plan and identifies any gaps or barriers to healthcare.
- Visit providers to manage and coordinate care for customers by reviewing medical and claim information, ensure compliance with approved services and fees and discuss cases with hospital staff and physicians.
- Establishes a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.
- Work with physicians to evaluate complex cases and receive appropriate clinical expertise on diagnosis and treatment plans.
- Responsible for delivering to customers clinical programs including case management, chronic condition management, lifestyle coaching, pre assignment assessment and any other program delivered by global clinical operations.
- Coordinate care with other nurses from other regions around the world when a need for local or regional expertise is important for better care or to comply with regulations.
- Maintains accurate workflow and process documents.
- Adheres to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures.
- Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
- Demonstrates sensitivity to culturally diverse situations, clients and customers.
- Serve as clinical liaison to Clients.
- Other duties as assigned.
Employment Type
Full Time
Company Industry
Department / Functional Area
Key Skills
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