Case Manager, RN – Bilingual
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Job Description
Bilingual RN Case Manager coordinating care, authorizations, and medical-necessity reviews for MedWatch’s population health programs. Managing patient cases, payer communications, care plans, and quality improvement remotely.
Responsibilities:
- Manage an individual caseload using the Case Management process
- Authorize services and review treatment plans for medical necessity and standards of care
- Maintain ongoing communication with providers, payers, patients, caregivers, social workers, insurance teams, and other healthcare team members
- Develop, update, and maintain accountability for Case Management plans
- Assess patient problems, determine goals and interventions, and document case notes
- Verify benefit constraints with payer offices
- Verify medical necessity of ordered care and equipment with providers and vendors
- Arrange quality patient care according to patient needs, physician orders, and available benefits
- Manage Case Management files and maintain responsibility for the Case Management file
- Identify alternative treatments and prepare cost-benefit analyses when extra-contractual services may be appropriate
- Connect patients with community resources and funding sources
- Document all case actions and complete case records in the computer system
- Prepare timely reports to payers detailing case actions, results, and continuing plans
- Maintain billing in the computer system as appropriate
- Maintain contact across the continuum of care and periodically monitor chronic-condition cases
- Negotiate with providers to maximize medical benefits and make network referrals
- Address non-medical issues involving patient safety or welfare
- Consult regularly with the Director of Case Management and inform the supervisor of complaints or issues requiring escalation
- Participate in the Quality Management Program and identify opportunities for service improvement
- Provide input in the annual performance evaluation of the assigned Case Management Assistant
Requirements:
- Registered Nurse (R.N.)
- Current, active, and unrestricted RN license in the state of current practice and residence within the United States or its territories
- Bachelor's degree in a health-related field preferred
- 7 years of varied clinical experience preferred
- Good organizational and time-management skills
- Excellent verbal and written communication skills
- Ability to handle difficult situations tactfully and diplomatically
- Effective problem-solving and decision-making skills
- Strong computer skills
- Proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint
- Fluent English and Spanish, with strong reading and writing abilities in both languages
- Ability to manage moderate-complexity cases independently and contribute to team goals
- Must obtain a URAC-recognized certification in Case Management within 3 years of hire
- Ability to work in the United States without employer sponsorship
Benefits:
- Paid time off
- Medical insurance
- Dental insurance
- Vision insurance
- Short-term disability
- Long-term disability
- Life insurance
- AD&D insurance
- 401(k) with match
- Critical illness coverage
- Legal plan
- Identity theft coverage
- Pet insurance
- Discount programs
- Bonus program eligibility
- Pay differential for bilingual Spanish-speaking employees
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