Nurse Case Coordinator Jobs

Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements

Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)

Requires at least 5 years of prior experience in nursing, healthcare or related field

Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions.

Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable.

Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes

Care Coordination and Case Management for WTC responders

Assess active members for case-management service needs as clinically indicated

Develops Intensive case management Plan of Care and necessary follow-ups

Coordination with case management for post-discharge outreach

Address the unique health care needs of individual members and improve member satisfaction with the Program

Review of authorizations for medical necessity (prior authorization/prospective reviews and retrospective authorizations) as related to member’s WTC certified condition(s)