Case Manager RN
Spectraforce
US
Remote
7 days ago
Job Description
Case Manager (Nurse RN 3)
Remote in California
(Position is mostly remote, unless technical issues exist, it may require trip to closest office. Also, infrequent in person meetings in closest office.)
3+ months
Shift- 10:30am -7:00pm
Summary:
The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. The Regional Registered Nurse Case Manager will report to the FEP Care Management Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member’s needs.
Job Responsibilities:
• Coordinate care for lower level of care such Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community program as appropriate
• Perform effective discharge planning and collaborate with member’s support system and health care professionals involved in the continuum of care
• Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease). Outreach to members with HEDIS Care Gaps to assist with closure
• Apply detailed knowledge of FEP PPO and Client's established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case
• Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type
• Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
• Recognize the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
• Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
• Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
• Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation
Skills:
• Verbal communication skills, attention to detail, and problem solving skills.
• Verbal and written communication skills, attention to detail, and problem solving skills.
• Basic ability to work independently and manage one’s time.
• Basic knowledge of the information and techniques needed to diagnose and treat human injuries and diseases.
• Basic ability to analyze data and accurately document and record results.
• Understands the Nurse Practice Act and legal consequences of nursing action.
Education/Experience:
• Requires a current CA RN License. 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
• 3+ years managed care experience preferred
• Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources preferred
• Behavioral health, oncology, or OB/NICU/pediatrics experience preferred
• Strong electronic clinical documentation skills, independent problem identification and resolution skills
• Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
• Competent understanding of NCQA and federal regulatory requirements
• Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making
• Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
About Us: SPECTRAFORCE is one of the fastest-growing workforce solutions firms in the United States. As a diversity-owned business, we place human connection at the heart of everything we do, building strong relationships with both clients and candidates to fill roles successfully. Our teams in North and Central America and India serve more than 150 Fortune clients globally, leveraging custom AI technology to provide direct hire, executive search, nearshoring, offshoring, and project staffing solutions.
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.
Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.
California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting NAHR@spectraforce.com.
LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer.
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $40.00/hr.
Remote in California
(Position is mostly remote, unless technical issues exist, it may require trip to closest office. Also, infrequent in person meetings in closest office.)
3+ months
Shift- 10:30am -7:00pm
Summary:
The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. The Regional Registered Nurse Case Manager will report to the FEP Care Management Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member’s needs.
Job Responsibilities:
• Coordinate care for lower level of care such Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community program as appropriate
• Perform effective discharge planning and collaborate with member’s support system and health care professionals involved in the continuum of care
• Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease). Outreach to members with HEDIS Care Gaps to assist with closure
• Apply detailed knowledge of FEP PPO and Client's established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case
• Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type
• Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
• Recognize the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
• Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
• Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
• Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation
Skills:
• Verbal communication skills, attention to detail, and problem solving skills.
• Verbal and written communication skills, attention to detail, and problem solving skills.
• Basic ability to work independently and manage one’s time.
• Basic knowledge of the information and techniques needed to diagnose and treat human injuries and diseases.
• Basic ability to analyze data and accurately document and record results.
• Understands the Nurse Practice Act and legal consequences of nursing action.
Education/Experience:
• Requires a current CA RN License. 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
• 3+ years managed care experience preferred
• Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources preferred
• Behavioral health, oncology, or OB/NICU/pediatrics experience preferred
• Strong electronic clinical documentation skills, independent problem identification and resolution skills
• Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
• Competent understanding of NCQA and federal regulatory requirements
• Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making
• Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
About Us: SPECTRAFORCE is one of the fastest-growing workforce solutions firms in the United States. As a diversity-owned business, we place human connection at the heart of everything we do, building strong relationships with both clients and candidates to fill roles successfully. Our teams in North and Central America and India serve more than 150 Fortune clients globally, leveraging custom AI technology to provide direct hire, executive search, nearshoring, offshoring, and project staffing solutions.
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.
Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.
California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting NAHR@spectraforce.com.
LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer.
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $40.00/hr.