Nurse Case Manager Resume Samples

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A Mayert

Annie

Mayert

8842 Hudson Skyway

Los Angeles

+1 (555) 196 9697

8842 Hudson Skyway

Los Angeles

Phone

p +1 (555) 196 9697

Experience Experience

Los Angeles, CA

Nurse Case Manager

Los Angeles, CA

Herman Group

Los Angeles, CA

Nurse Case Manager

Assist with planning, developing and implementing health and wellness (well-being) promotion programs
With the managers, participate in the training process of new nurse case managers, including but not limited to shadowing & call monitoring
Functions as the case manager during any period of Clinical Center inpatient hospitalization, collecting and documenting protocol data
Develops reporting/tracking/trending to present to DFSM management
Assist with managing inventory for medical supplies to include ordering and stocking
Home health aides help with bathing, dressing and feeding the hospice patient as well as provide assistance with other activities
Maintaining accurate record of case management assessment and intervention including benefit and cost analysis for data collection and trending

Phoenix, AZ

RN Nurse Case Manager

Phoenix, AZ

Carroll and Sons

Phoenix, AZ

RN Nurse Case Manager

Works with member, member’s family, and providers to develop and implement a comprehensive individualized service plan
Maintains strong working relationships with Health Plan Medical Directors, Inpatient Managers, POD Inpatient Medical Directors and POD administrators
Notifies hospital and/or provider of recommended changes in level of care when applying approved criteria and established policies and guidelines
Attends and actively participates in assigned POD Inpatient Manager Meetings as scheduled
Participates in education of providers regarding Health Services policies and procedures
Performs other related duties and projects as assigned
Works with member to close clinical and pharmacy gaps and to mitigate non-clinical barriers to care

present

Houston, TX

RN Nurse Case Manager Specialist

Houston, TX

Hansen, Ondricka and Hettinger

present

Houston, TX

RN Nurse Case Manager Specialist

present

Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelines
Actively participates in identification of opportunities for improvement and assists with action plan development and problem resolution
Acts as a liaison for the health plan with outside entities, including, but not limited to physicians, hospital, health care vendors and facility Case management Departments
Concurrently enters all information into the healthplan’s computer documentation system ensuring complete and accurate information per established policies and guidelines
Supports an environment which fosters teamwork, cooperation, respect, and diversity. Establishes and maintains positive communication and professional demeanor with coworkers, delegates, vendors and members at all times. Demonstrates and supports commitment to organizational and plan goals and objectives
Prepares report and conducts analysis of POD specific information & communication. Reviews these results with POD Inpatient Medical directors prior to Inpatient Utilization Manager Meetings
Reviews selected claims and retrospective requests for certification and follow-up as necessary with HeatlhServices Supervisor, Manager of Inpatient Utilization or Medical Director

Education Education

Bachelor’s Degree in Nursing

Clark Atlanta University

Bachelor’s Degree in Nursing

Skills Skills

Strong professional level of knowledge and comprehensive clinical assessment skills in the areas of population and chronic disease management
Detail oriented with strong organizational and analytical skills as well as the ability to prioritize and coordinate multiple tasks
Ability to exercise professional judgment and assume responsibility for decisions which have an impact on people, costs and quality of service
Ability to edit, search, sort/filter, format/use styles, create tables and use Pivot Tables
Strong attention to detail
Ability to troubleshoot or explain basic hardware and software errors and work with a Technician by remotely to perform step-by-step repairs
Strong knowledge of case management, specialty area, medical terminology and conditions, insurance industry as well as company policies and procedures
Knowledgeable of the values offered with integrated care
Strong knowledge of healthcare, government and industry trends
Excellent verbal, written, and presentation skills with the ability to convey technical issues in a clear, concise and effective manner

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Nurse Case Manager Resume Examples & Samples

1+ year of Clinical Hospital experience
Home Care experience
Geriatric experience
Excellent articulation, phone assessment skills, and computer skills

Nurse Case Manager Resume Examples & Samples

Authorizing vendor services on skilled need and medical necessity; negotiate fees for Durable Medical Equipment (DME) and services needed
Promoting active involvement, knowledge and initiative to members regarding their health care management and negotiating healthcare systems in order to preserve benefit resources
Maintaining accurate record of case management assessment and intervention including benefit and cost analysis for data collection and trending
Performing special projects and assignments as directed by management
Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services
AAS Nursing / RN
3+ years of nursing experience in Medical, Surgical
1+ year of case management, utilization review, or home care experience
Knowledge of Milliman/InterQual and Medicare/Medicaid coverage guidelines and discharge planning
Strong communication skills with the ability to interact with all levels of management

Nurse Case Manager Resume Examples & Samples

4-10 years of experience
4+ years of UR or CM experience, or recent acute care nursing experience
Strong working knowledge of Medicare and reimbursement plans
Ability to conduct comprehensive patient assessments and analyze data to formulate an appropriate plan for patient management
Knowledge of clinical and fiscal interactions across the continuum of care

Nurse Case Manager Resume Examples & Samples

College degree preferred and valid New York State Registered Nurse (RN) license required
Minimum of 2 years medical and surgical clinical experience
Minimum of 1 year of case management, utilization review, or disease management
Strong experience with discharge planning
Strong knowledge with standard utilization criteria (Milliman, Interqual), Medicare and Medicaid coverage guidelines, health claims processing, medical coding and interpreting provider contracts
Excellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capability
Computer and organizational skills, ability to manage competing priorities, multi-task with results oriented outcomes and work in a fast paced environment

Nurse Case Manager Resume Examples & Samples

Provides telephonic case management in a workers’ compensation environment
Conducts and documents an initial assessment with the injured worker, employer, and provider to collect information needed to collaboratively formulate a case plan
Develops appropriate treatment plans with a balance between quality of care and cost-effectiveness
Facilitates early intervention for return to work programs
Provides medical and/or disability case management services including review and evaluation of WC claims
Participates in file reviews, roundtables on complex and catastrophic cases
Documentation is clear, concise and reflects strong technical and clinical knowledge and effective communication skills
Provides effective vendor management when assessing or managing cases. This includes appropriate timing of vendor use, cost benefit, vendor selection and vendor purpose
Supports other team members to enhance overall team performance
Provides prospective, concurrent and retrospective review services on cases assigned
Optional on-call responsibilities
Travel for file reviews
Coverage for Nurse Case Managers on team
Performs additional duties on specified accounts, such as evaluation, triage, and chart reviews based on predictive modeling scores or resolution role for peer to peer nursing consultation on aged, duration claims focusing on resolution and end case outcome
Performs advanced duties such as life care planning when requested with appropriate certifications and training
Active and unencumbered Registered Nurse licensure in state of residence
URAC recognized certifications in one of the following: ACM, CCM, CDMS, CMAC, CMC, CRC, CRRN, COHN, COHN-S, RN-BC or agreement to obtain this within 4 years from date of hire
Ability to work independently and/or in a team setting
Seeks appropriate guidance of supervisory personnel
Bachelors degree (or higher) in a health or human services related field
2-3 years prior experience in workers’ compensation case management and/or utilization review process
Prior experience in ancillary services operations to include Life-care planning, Medicare set asides, cost projections as well as auto and liability case management

Nicu Nurse Case Manager Resume Examples & Samples

Associate’s or Bachelor’s Degree (or higher) in nursing and/or a health-related field accredited diploma nursing school
2+ years of clinical experience
Proficiency in the use of personal computers and supporting software in a Windows-based environment
Working knowledge of case/care management principles
Basic knowledge of health care contracts and benefit eligibility requirements

Nurse Case Manager Resume Examples & Samples

Experience managing large case loads
Work experience as a licensed RN in one or more of the following areas: Geriatrics, Discharge Planning, Case Management, Assessment, Acute, Sub-Acute, Long-Term Care (LTC), Health Insurance, Home Care Environment, Homeless, Addiction, Foster Care
Ability to troubleshoot or explain basic hardware and software errors and work with a Technician by remotely to perform step-by-step repairs
Intermediate skills with a Corporate email system including using and sharing calendar rights, MS Word, MS Excel and electronic patient health information (PHI) database usage (medical records database)
Ability to edit, search, sort/filter, format/use styles, create tables and use Pivot Tables
Experience working with a frail adult or elderly population
Knowledge of current community health practices for the frail adult population and cognitive impaired seniors
Knowledge of InterQual
Care management knowledge, including the concepts and philosophy and relevant standards of patient care
Understanding of and sensitivity to cultural differences and needs of the community
Experience with multiple Medicaid managed care plan products

Nurse Case Manager Resume Examples & Samples

2 years of medical and surgical clinical experience, plus a minimum of one 1 year of case management, utilization review, or disease management experience
Strong knowledge of standard utilization criteria (Milliman, Interqual), Medicare and Medicaid coverage guidelines, health claims processing, medical coding and interpreting provider contracts
Demonstrated computer and organizational skills
Results-driven
Telemetry skills
Certified Case Manager

Xerox / Bunch Telephonic Nurse Case Manager Resume Examples & Samples

Case management activities demonstrating the appropriate use of field case management per established Bunch protocols. - Case management activities demonstrating the appropriate use of PA and PR tools. - Maintains a minimum closure ratio of 1:1. - Actively supports preferred provider relationships to optimize cost effective quality outcomes. - Assists claims personnel by reviewing records regarding mechanism of injury and diagnosis. - Actively participates in roundtables per prescribed Bunch protocols to facilitate claim resolution. - Participates in file review, account meetings and other formalized activities as required per account. - Demonstrates effective communication and builds professional relationships to support the mission and goals of the organization. - Adheres to Bunch policies. - Protects confidentiality of medical and case information in accordance with jurisdictional requirements. - Identifies, evaluates and communicates quality issues to Nurse Manager. - Performs case management services within the scope of licensure, policies, and jurisdictional requirements
Physical demands / : prolonged sitting; use hands to finger or handle objects or controls; occasionally reach with hands and arms; occasionally lift and/or move up to 15 pounds; frequent talking and hearing; prolonged viewing of computer monitor
Work environment / : indoor office environment; minimal noise level

Corporate Health Nurse & Case Manager Resume Examples & Samples

Five or more years of nursing experience of which 3 years are in emergency room nursing, critical care, occupational health, urgent care or ambulatory clinic
Knowledge of case management, workers’ compensation, and governmental regulations
Leverage client needs with business needs
Demonstrated ability to adapt working style and work in fast-paced corporate environment
Demonstrated sense of urgency and ability to appropriately escalate concerns to supervisors/ regional managers

Field Nurse Case Manager Resume Examples & Samples

Active RN or LPN license
Prior clinical experience preferably in an acute care or skilled nursing setting
Utilization Review Experience strongly preferred

Nurse Case Manager, / II / Senior Resume Examples & Samples

Qualified candidates must have a current unrestricted Wisconsin RN license, BSN preferred, and at least 3 years of pertinent clinical experience
At least 5 years clinical experience strongly preferred
Case management, med/surge, home health and/or discharge planning experience preferred
Must have strong oral, written and interpersonal communication skills, PC skills to include word processing, spreadsheet, and database applications, organizational and problem-solving skills, and decision-making skills

Rn-nurse Case Manager Resume Examples & Samples

Requires a BA/BS in a health related field
Current, unrestricted RN license in the state of Louisiana required
Strongly prefer previous experience in behavioral health, home health, emergency room and/or discharge planning
Strongly prefer previous experience with substance abuse, homelessness, and/or dept. of corrections

Nurse Case Manager Resume Examples & Samples

Coordinates services and authorizations for members with unusual and complex cases and for members transitioning from AHCCCS Health Plans to the American Indian Health Program
Devises and reviews data reports to identify high need/high costs members for care coordination and leads regularly scheduled clinical discussions with IHS/638 Providers and/or behavioral health contractors/providers regarding high utilization, trends, and complex cases
Participates in outreach efforts with IHS/638 Facilities, along with other Care Coordination Team Members
Coordinates medical care for transplants in conjunction with the AHCCCS Division of Healthcare Management, including specialized transportation, meals and lodging
Develops reporting/tracking/trending to present to DFSM management
Independent decision making in a Virtual Office environment
Possesses an Arizona RN or LPN license, in good standing
Demonstrated knowledge of case management concepts, principles, and strategies
Proficient knowledge of Medical and Behavioral Healthcare management and delivery; the ability to interpret clinical information and assess implications for treatment
Excellent communication, verbal and written skills; experienced in documentation and reporting of data and trends
Strong organizational skills to coordinate, monitor, and report on multiple cases simultaneously
Certified Case Manager experience
Strong interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds
Familiarity with American Indian Tribes’ programs and policy

Complex Nurse Case Manager Resume Examples & Samples

Active, unrestricted CA RN license (or active, unrestricted CA LVN license for grandfathered LVNs in the department)
Current, unrestricted CA Drivers License
Current, BLS certification
BSN from an accredited US nursing program
Case management, home care, or discharge planning experience required – minimum one year
PREFERRED
Case management certification, or expected to attain CCM (case management certification) within two years of hiring
Experience working in EPIC and EPIC Tapestry

MMP Nurse Case Manager Resume Examples & Samples

Visit Medicaid members in their homes and/or other settings, including community centers, hospitals or providers' offices
Access to reliable transportation to travel to member homes or other locations within service delivery area
3+ years of clinical experience in a hospital, acute care, home health/hospice, direct care or case management
Case Management experience including Certification in Case Management

Nurse Case Manager Resume Examples & Samples

Maintains current RN license and/or any professional designations that may be required with the jurisdiction
Nurse case managers hired prior to 8/01/2012 will obtain a URAC-recognized certification in case management no later than 7/31/2016
Demonstrates mastery of the nursing process (assess, plan, implement, coordinate, monitor and evaluate) in accordance with established national standards for case management activities
Assessment activities collect in depth information, from the injured worker and all other relevant sources, needed to develop a comprehensive, collaborative case management plan to address client needs. Established case management contacts are performed per account requirements
Plans of care establish specific objectives, short and long term goals, timeframes for follow-up and response to service, resources to be utilized, collaborative approaches to be used and actions designed to meet the client’s needs. Plan of care is action oriented and time specific. Incorporates barriers and guidelines into action plans. Involves EE and health care team in the formation of action plans to achieve optimal outcomes
Implementation of case management plan leads to accomplishing goals set forth. Implementation occurs at appropriate intervals to achieve quality, cost effective outcomes
Demonstrates the ability to coordinate care in an organized manner to secure, integrate and modify resources necessary to accomplish case management goals
Monitors the case management plan and its progression by ongoing contact with all relevant sources of information to determine effectiveness of plan of care and progression of work status. Estimated length of disability is defined and monitored
Performs repeat evaluations of the effectiveness of the case management plan to reach quality, cost effective outcomes and goals. Modifies plan of care as indicated to achieve desired objectives and goals. Evaluates the recovery needs of the injured worker by ongoing contacts with relevant sources: provider(s), employer, employee, claims personnel, legal representatives
Provides estimates for future care (type of care and potential costs for same) when requested by the claims examiner for reserving purposes
Demonstrates the ability to perform UR activities for all requested services, utilizing appropriate guidelines for medical necessity determination and in compliance with URAC Standards
Case management activities demonstrating the appropriate use of field case management per established Bunch protocols
Case management activities demonstrating the appropriate use of PA and PR tools
Maintains a minimum closure ratio of 1:1
Actively supports preferred provider relationships to optimize cost effective quality outcomes
Assists claims personnel by reviewing records regarding mechanism of injury and diagnosis
Actively participates in roundtables per prescribed Bunch protocols to facilitate claim resolution
Participates in file review, account meetings and other formalized activities as required per account
Demonstrates effective communication and builds professional relationships to support the mission and goals of the organization
Adheres to Bunch policies
Protects confidentiality of medical and case information in accordance with jurisdictional requirements
Identifies, evaluates and communicates quality issues to Nurse Manager
Performs case management services within the scope of licensure, policies, and jurisdictional requirements

Nurse Case Manager Resume Examples & Samples

Conversant knowledge and experience with case management care coordination, and/or utilization review
Track record and comfort in collaborating with physicians
Three (3) years bedside experience in the relevant clinical specialty (e.g., care managers for pediatric patients should have pediatric nursing experience)

Registerred Nurse Case Manager Resume Examples & Samples

Assesses discharge needs of all high-risk patients (and others referred). Identifies resources available to address the needs identified, coordinate referrals, and document plan
Utilize community resources to support patient’s post hospital needs. Documents choice in available resources
Performs admission and continued stay reviews. Provides clinical information to payers upon request for certification and reimbursement of care. The RN Case Manager discusses alternate levels of care with physician. Refers cases not meeting acute care criteria to Physician Advisor as needed
Facilitates and provides education of hospital staff, physicians, patients, and caregivers for purposes of efficient resource utilization
The RN Case Manager is knowledgeable of all JCAHO, HCFA, and state/federal requirements for provision of care, planning, and documenting
Tracks resource statistics to identify improvement opportunities. Reports findings at medical staff and other hospital committee meetings
Graduate of an accredited diploma, associates, or baccalaureate degree nursing program. (required)
Minimum of 3 years clinical experience in area in which Case Management was performed. (preferred)
At least one year experience in utilization review, resource management, discharge planning, or case management. (preferred)

Register Nurse Case Manager Resume Examples & Samples

Current FL licensure as an RN
6 months of Case Management experience
Knowledge of CMS guidelines and experience working with payor specific guidelines and contractual rules preferred
Critical thinking skills, decisive judgment and the ability to work with minimal supervision meeting firm deadlines
Assertive and persuasive communication skills, action oriented

Occupational Nurse Case Manager Resume Examples & Samples

Experience in Occupational Medicine
Familiarity with L&I’s Claims and Account System
Washington Workers’ Compensation Claims Certification
Experience with in-house workers’ compensation claims programs

Nurse Case Manager Resume Examples & Samples

Devises and reviews data reports to identify high need/high cost members for care coordination and leads regularly scheduled clinical discussions with IHS/638 Providers and/or behavioral health system/providers regarding high utilization and trends, and complex cases
Participates in Care Management Services Unit (CMSU) care coordination efforts, such as infrastructure development, review of high need/high cost evaluation to inform clinical decision, working with other AHCCCS divisions
Participates in process improvement and other special projects, work in groups and committees to improve the efficiency of care coordination, utilization management and other CMSU function
Works with the tribes to establish rapport and close collaboration with providers and facilities
Serves as a back-up resource to all clinical functions in the CMSU
Potential travel may be required
Current Arizona RN or LPN license, in good standing
Knowledge of case management concepts, principles and strategies
Interpret clinical information and assess implications for treatment, based upon knowledge of Medical and Behavioral Healthcare management and delivery
Excellent communication, verbal and written skills
Organizational skills to coordinate, monitor and report on multiple cases simultaneously
Ideal candidate will be a Certified Case Manager
Familiarity with American Indian Tribes/programs and policy
Analytical skills to identify and correlate specific patterns in documentation and reporting of data and trends

RN Nurse Case Manager Resume Examples & Samples

Minimum 5 years clinical experience in an acute care setting
Previous Case Management/Utilization Review experience preferred
Established Leadership skills, with critical thinking ability
Ability to collect, organize, and analyze data
Proficient with Computer programs
Ability to communicate both written and verbally across multiple levels

Nurse Case Manager Resume Examples & Samples

Provide medical support to patients and health care providers, including but not limited to education on specific diseases and therapies and disease management
Telephone support (including maintenance calls and adherence support both inbound and outbound as needed)
Database management and ongoing auditing of files and information captured
Administer and adhere to case-management protocols, including clinical monitoring, data collection, on-going patient follow-up, compliance, therapy disruption/discontinuation monitoring, adverse event reporting and liaison with primary healthcare providers
Prepare for and attend extensive, specialized training sessions for specific therapies provided by the pharmaceutical team
With the managers, participate in the training process of new nurse case managers, including but not limited to shadowing & call monitoring
Support and collaborate with other program staff in the development and implementation of disease management programs including clinical requirements, write texts, manuals or patient pamphlets, develop compliance program parameters, needs assessments and protocols
Provide feedback regarding current protocols, databases, processes, inter-departmental relationships
Responsible for reporting all Adverse Events to the assigned units/departments
Bachelor of Science in Nursing (BSN, BScN), or Bachelor of Nursing (BN) or Bachelor of Science (BS) with a Major in Nursing or Registered Nurse (RN) diploma or registered practical nurse (RPN) diploma, advanced degree or specific practice management experience preferred, with five (5) years of Nursing experience
Requires a minimum of two (2) years in public or private third party reimbursement arena or pharmaceutical industry in sales (not required, but an asset), managed care, or clinical support, or related experience
The preferred candidate is a nurse with healthcare and case management experience in medical or hospital practice or the insurance or bio-pharma industry

Nurse Case Manager Resume Examples & Samples

Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans
May direct and/or supervise the work of any LPN/LVN, LSW, LCSW, LMSW, and other licensed professionals other than an RN, in coordinating services for the member by, for example, assigning appropriate tasks to the non-RN clinicians, verifying and interpreting member information obtained by these individuals, conducting additional assessments, as necessary, to develop, monitor, evaluate, and revise the member’s care plan to meet the member’s needs, and reviewing and providing input on the non-RN clinicians performance on a regular basis
Requires a BA/BS in a health related field; 3 years of clinical experience (4 years and 5 years respectively for higher level); or any combination of education and experience, which would provide an equivalent background
Current, unrestricted RN license in Virginia
As applicable, multi-state licensure is required if this individual is providing services in multiple states
Willing and able to work in the field
**May be a level I or II depending upon incumbent’s related skills, experience, and knowledge.****

Nurse Case Manager Medicare State of Georgia EGR Resume Examples & Samples

Qualified candidates must have a current unrestricted Georgia RN license, BSN preferred, and at least 3 years (5 years for higher level) of pertinent clinical experience
Case management certification (CCM) preferred
Case management, hospital, med/surg, home health and/or discharge planning experience preferred
Requires knowledge of care management assessment techniques, provider community, and community resources
Must have strong negotiation skills and ability to handle complex issues
Must be able to be licensed in multiple states on a timely basis
May be required to work some corporate paid holidays and/or weekends
Employer Group Retiree account experience preferred
May be a Nurse Case Manager I, II, or Sr depending upon level of relevant experience.**

Nurse Case Manager / St Petersburg, FL Resume Examples & Samples

Ability to lead and coordinate activities of a diverse group of people
Demonstrated ability in problem solving and communications
Working knowledge of and basic skills with computers
Florida Registered Nurse license (R.N.) or Licensed Practical Nurse (L.P.N.) is required
Emergency Nursing and Case Management preferred
Required to use fine motor skills (typing/data entry), and reach with hands and arms
Must be able to lift up to 25 lbs
Subject to varying and unpredictable situations, many interruptions, multiple calls and inquiries, and change
May be required to work long hours and holidays

MMP Nurse Case Manager Resume Examples & Samples

Provide a complete continuum of quality care through close communication with members via in - person or on - phone interaction
3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care or case management
Computer / typing proficiency to enter / retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications
Experience working with the needs of vulnerable populations who have chronic or complex bio - psychosocial needs

Nurse Case Manager Resume Examples & Samples

Provide medical support to patients and health care providers, including education on specific diseases and therapies
Liaise with health care providers, pharmacies and infusion clinics, and other agencies as required, to coordinate infusions, drug delivery and resolve issues as they arise; support the field team on an ongoing basis
The Nurse Case Manager will also be assigned other duties and tasks as required from time to time
A Bachelor’s degree or registered nurse (RN) diploma, advanced degree or specific practice management experience preferred, with five (5) years of Nursing experience
Bilingualism (French and English) strongly required
Experience in dermatology and/or dermatology an asset
Strong patient focus
Strong ability to multi-task
Superior customer service skills
Internet-research and computer savy; has strong verbal and written communication skills, problem solving skills and is a team player
Demonstrate teamwork abilities

Field RN Nurse Case Manager Resume Examples & Samples

Ensures member access to services appropriate to their health needs
Conducts assessments to identify individual needs and creates a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
Coordinates internal and external resources to meet identified needs
Monitors and evaluates effectiveness of the care management plan and modifies as necessary
Assists in problem solving with providers, claims or service issues

Nurse Case Manager Resume Examples & Samples

Experience with making diagnoses and choosing, initiating, and modifying selected therapies in order to assist patients with optimizing their level of function and self-care
Knowledge of patient education principles and the management of complex medical, psychosocial, and financial problems in order to enhance patient adherence to individualized treatment plans and train peers and staff
Knowledge of Case Management Society of America (CMSA) case management standards and ethics, Utilization Review Accreditation Commission (URAC) case management organizational standards, and Joint Commission for Accreditation of Health Care Organizations (JCAHO) case management standards
Ability to seek feedback from peers, professional colleagues, clients, and research outcomes in order to expand clinical knowledge, enhance role performance, and increase knowledge of professional issues
TS/SCI clearance
BA or BS degree
Experience with working in a government environment, including the DoD or Department of Veterans Affairs (VA) MTF
Ability to consult with healthcare providers at all levels and negotiate with outside providers for services and products in order to obtain client services and support

Medical Nurse Case Manager Resume Examples & Samples

Conduct medical and disability case management consistent with professional standards and best practices for management of occupational and/or non-occupational illness/injury. (Assessment, Intervention, Evaluation)
Facilitate medical access for the injured worker to the highest quality medical services utilizing appropriate provider networks
Communicate with employee, physician and employer
Effectively collaborate with customer and claims team partners
Ongoing analysis of cost containment program process and outcomes in order to maximize direction of injured worker to quality medical care
Coordinate medical care services
Execute case management assignments based on clearly defined referral criteria
Document use of best practice references such as standardized disability duration guidelines and medical management protocols
Advises and make recommendations regarding medical and disability management
Conduct medical technical and medical claims procedure orientation for new hires in the department
Organize and conduct training sessions for the workers' compensation claims management team
Manage and support multiple projects in a fast-paced environment
Minimum of six (6) years or more of experience in professional clinical practice (Ortho, Rehab, ICU/ER, or Occupational Health)
Three (3) years in a case management role preferred
Knowledgeable in workers' compensation - medical and disability case management and/or utilization review / utilization management practices and procedures desired
Extensive knowledge of medical and pharmaceutical terminology
Computer proficiency with basic claims system and Microsoft Office, including Word and Excel
Successful experience in conflict management and negotiations
Self-motivated, excellent oral and written communication skills, documentation and follow-up
Knowledge of related employment benefits (ADA, FMLA, state disability legislation, LTD, SDI, group health benefits) and how they interact with workers compensation benefits
High degree of initiative; proven team player

Nurse, Case Manager Resume Examples & Samples

Demonstrated organizational skills
Ability to lead and coordinate activities of a diverse group of people in a fast paced environment
Strong computer literacy
Licensed RN, LVN or LPN and willing to be licensed in multiple states as applicable
At least 2 years of acute care experience required
Case Management Certification and/or experience preferred

Nurse Case Manager Resume Examples & Samples

Identifying opportunities for health promotion and illness preventions
Perform face-to-face patient visits in the home or physician office setting. All patient visits are “hands-off” visits for educational purposes only
Attend accountable care training sessions, as required
Work with the PPMSI medical management team to develop tools and methods of identifying high risk patients using payor information as well as in-house analysis
Ensure targeted high risk chronically ill patients are enrolled in care management programs according to program requirements
Coordinate efforts with the Quality Management team to meet quality gate targets for identified patients, as required by the accountable care programs
Assume responsibility for special projects as assigned by the Medical Director
Advocacy, communication, education and counseling, and resource research skills
Core philosophy or values consistent with a family-center approach to care
Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs
Current unrestricted California RN or LVN Licensure required
Minimum of 3-5 years of previous experience in a managed care organization or other comparable experience
Experience and competence with Microsoft Office( Excel, Word, Powerpoint) and internet-based
Excellent data gathering, data analysis and summary-level reporting skills
Ability to prioritize tasks and thrive in a highly productive environment
Ability to communicate effectively, both verbally and in writing, with executive clinical and non-clinical leadership, payor representatives and providers and their office staff
Strong professional level of knowledge and comprehensive clinical assessment skills in the areas of population and chronic disease management
Familiar with current clinical practices for adult and pediatric medical, surgical and psychiatric care
Familiar with standard review criteria such as Interqual and/or Milliman
Some regional travel required
RN- Registered Nurse or LVN- Licensed Vocational Nurse
Active, unrestricted California License
Ability to become proficient with care management information technology

Nurse Case Manager Resume Examples & Samples

Provides direct nursing care to an assigned caseload of patients utilizing the nursing process to assess, plan, intervene and follow-up on disease-related features as outlined in the clinical protocol
Coordinates patient schedules to meet the required protocol procedures, data collection time points and nursing care
Inputs and/or directs the input of patient travel and remuneration according to the protocol
Assists physicians in protocol-required skilled procedures, such as phlebotomy and intravenous catheter placement, pharmacokinetics and interdermal antigen skin testing
Orders labs, x-rays and other diagnostic procedures prescribed by the protocol and/or clinically indicated in a computerized patient management system
Reviews results and alerts physicians of abnormal outcomes or problematic trends and collaborates on protocol or practice required interventions
Serves as the main liaison between an assigned caseload of patients and other health care team members to ensure appropriate intervention is instituted for any research or health related adverse event
Instructs patients on findings of assessment data and treatment plans and follows up with patients by phone
Monitors and ensures informed consent forms have been signed
Collaborates with community health care providers for research integrity
Functions as the case manager during any period of Clinical Center inpatient hospitalization, collecting and documenting protocol data
May examine and triage patients during health care visits per protocol interventions
Possession of a current professional license as a registered nurse (RN)
Minimum of six (6) months nursing/clinical experience
Ability to function independently and/or collaboratively within a team setting
Highly effective problem-solving, planning and organizational skills
Experience effectively managing complex research programs in a large institutional setting
Working knowledge of clinical research concepts, ethics, processes and protocol implementation and management
Background knowledge in clinical trials or pharmaceutical projects
Prior experience in adult/pediatric clinical trials management
Experience with international clinical trials
Case management in a pharmaceutical, biotechnology and/or clinical environment

Reg Nurse Case Manager PRN Resume Examples & Samples

Coordinates and facilitates patient care progression throughout the continuum
Collaborates with Social work on the facilitation of transfers internally to SNF, ARF, LTACH, Home Care
Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary team in order to effect timely, appropriate patient management. Identifies and, in partnership with the care team, resolves delays and barriers to discharge
Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting
Participates in patient rounding activities: daily caseload rounding to establish priorities for self, SW and high risk TCC, multidisciplinary care coordination/discharge planning rounds, hand off report to nursing staff, hand off report to post-acute facilities SCC and PCC, physician advisor rounds and weekly LOS rounds
Participates in committee meetings
Addresses/resolves items impeding diagnostic or treatment progress
Participates in Data Collection and inputting (e.g., Avoidable Days, Readmissions, Important Message letter delivery, Condition Code 44, etc.)
Ensures compliance with CMS Conditions of Participation, standards of the accrediting bodies and the state mandated revised code
Minimum of three years of clinical nursing experience required
Minimum of two years of experience in Utilization Review, Quality, or Care Management preferred
Knowledge of acute care regulatory/accreditation requirements preferred
Discharge planning and/or Quality Improvement experience preferred

RN Nurse Case Manager Specialist Resume Examples & Samples

Notifies hospital and/or provider of recommended changes in level of care when applying approved criteria and established policies and guidelines
Completes opportunity report concurrently and any other reports or request for information in a timely manner
Evaluates each case for quality of care, documents quality issues and appropriately refers cases to the quality management coordinator
Reviews selected claims and retrospective requests for certification and follow-up as necessary with HeatlhServices Supervisor, Manager of Inpatient Utilization or Medical Director
Identifies and refers cases concurrently to CCIP or Rapid Response unit as appropriate and indicated in established policies and guidelines
Performs member/family interviews and assists in discharge plan development and coordination of care
Acts as a liaison for the health plan with outside entities, including, but not limited to physicians, hospital, health care vendors and facility Case management Departments
Maintains confidentiality in all aspects of operations. Complies with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information
Facilitates referrals for follow up care with delegated entities
Maintains strong working relationships with Health Plan Medical Directors, Inpatient Managers, POD Inpatient Medical Directors and POD administrators
Actively participates in network meetings as scheduled and requested
Activley participates in mandatory weekly CHT rounds
Prepares report and conducts analysis of POD specific information & communication. Reviews these results with POD Inpatient Medical directors prior to Inpatient Utilization Manager Meetings
Supports and carries out the Organizational Mission & Values
Registered Nurse graduated from an accredited Diploma, Associates Degree or Bachelor’s Degree Program
2-3 years clinical experience with at least 1-2 years in utilization review. Managed Care experience preferred
Knowledge of ICD-9 coding, CPT coding and Interqual guidelines for utilization review
Current and valid Texas Registered Nursing License required
Availability: flexible work schedule with ability to work weekends and cover evenings

RN Behavioral Health Nurse Case Manager Resume Examples & Samples

Provides suggestions for improvements and enhancements to wellness coaching programs based on data/experience
Conducts on-site or in-home face to face evaluations as requested by the member/caregiver, as determined per assessment of the member or when progress is not being made in achieving goals
Perform research on relevant topics in health promotion and disease prevention, as required for specific members
Consult with and assist team members in cases where a member’s behavioral health or emotional issues are impacting their ability to set and/or achieve goals
May actively participate in committees as assigned and act as Team Lead as assigned
Perform other related duties incidental to the work described herein

Telephonic Nurse Case Manager Resume Examples & Samples

Communication with claimants, medical professionals, claims staff and others to obtain information necessary to make sound medical decisions. In addition, responds to various written, telephone inquiries regarding status of case
Completes initial case evaluation by assessing injury/disability severity, treatment plans, functional abilities and physical job requirements and then establishes case-specific target return-to-work (RTW) dates
5+ Years clinical nurse experience with a preference for previous orthopedic, emergency room, critical care, home care or rehab care experience
Current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law
Good negotiation skills to effectively establish target return to work dates

Telephonic Nurse Case Manager Resume Examples & Samples

Manage assigned caseload of claims (including Workers' Compensation claims)
Communicate with injured employees, medical professionals, claims staff and others to obtain information necessary to make sound medical assessments regarding diagnosis and prognosis
Assess injury severity, extent of disability, treatment plans, functional abilities and physical job requirements to establish target return to work plans and/or strategy to manage future medical exposure
Respond to various written and telephone inquiries regarding status of case and post case facts in Liberty Mutual Insurance claims system

Nurse Case Manager Resume Examples & Samples

Registered nurse with a valid current license in appropriate jurisdiction(s) for NCM
Workers' Compensation case management experience strongly preferred
3 years clinical practice experience required in orthopedic, neurological, rehabilitation, medical/surgical or occupational health
Professional certification as a CCM (CDMS, CRC, CVE, and/or current CRRN) or willingness to pursue
Bachelor (or higher) degree in a health-related field and licensure as a health professional preferred
NO AGENCIES PLEASE **

RN Behavioral Health Nurse Case Manager Resume Examples & Samples

Telephonic and face-to-face outreach and coaching to members around their behavior change to improve health status, reduce health risks and improve quality of life
Assistance in the identification of member health education needs through various behavioral health assessments
Utilization of health prevention guidelines and general health and wellness strategies to achieve goals in the overall health of members
Assesses readiness to change and implements actions to assist members in moving through stages of change to reach their goals
Work with members to identify and set personalized health improvement plans and goals and support members in achieving those goals
Collaboration with team members such as Disease Management case managers, Service coordinators, pharmacist, Medical Director and member's provider
Works with members on opportunities to close gaps in their overall health status
Empowers members with skills to provide enhanced interaction with their providers

Nurse Case Manager Resume Examples & Samples

The preferred candidate is a nurse with healthcare and case management experience in medical or hospital practice or the insurance or bio-pharma industry; is internet-research and computer savy; has strong verbal and written communication skills, problem solving skills and is a team player
Registered Nurse or Registered Practical Nurse License for province of employment
Bilingualism (French and English) strongly preferred
Experience in hematology and/or oncology is an asset

Kort-nurse Case Manager Resume Examples & Samples

Must be a registered nurse (R.N.) with a current Indiana license
Minimum of one year of nursing experience as a R.N
One (1) year of Home Health experience preferred
Work positively and favorably with patients, families, and staff
Strong verbal and written communications skills
Flexible with diverse client assignments
Current automobile liability insurance and current unrestricted drivers license
CPR certification is mandatory immediately after employment

Nurse Case Manager, or, SF Bay Area Resume Examples & Samples

Applicant must live in Northern California, preferably Alameda County and may be required to do field visits
Case management experience is required
Medi-Cal Managed Care experience is required

Nurse Case Manager Resume Examples & Samples

Applicant must live in California
Requires a BA/BS in a health related field and 3-5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background
Case management experience is preferred
Experience in High Risk Obstetrics, Labor and Delivery, Post-Partum Maternity, Newborn Nursery, or NICU is preferred
Knowledge of community resources and programs for pregnant women
Must have excellent communication skills (written and verbal) as well as excellent interpersonal skills

Field Ltss Waiver Nurse Case Manager Resume Examples & Samples

High school diploma required, and at least 1 year of related experience
Strong knowledge of healthcare insurance industry, terminology, provider networks, contracting and credentialing
Ability and willingness to share knowledge
Detail oriented, with proven time management and organization skills (including the ability to engage in multiple tasks and meet deadlines/standards)
Be a positive role model and have the ability to work independently and in conjunction with co-workers of all levels
Strong analytical and problem-solving skills
Excellent communication skills – verbal, written and presentation
Working knowledge of SharePoint, Microsoft Word, Excel, & Access

RN Nurse Case Manager Resume Examples & Samples

Works with member, member’s family, and providers to develop and implement a comprehensive individualized service plan
Completes and files all assessments and implements the care plans within the timelines outlined by the state
Maintains a maximum weekly face to face visit scheduled of 8-10 member assessments weekly
Must be a Registered Nurse with a current, unrestricted Texas License
Must have strong computer skills using MS office products including Word, Excel, and Outlook
Must have reliable transportation, a valid and unrestricted driver’s license and proof of insurance
The ability to travel to members’ homes, and other locations within the service delivery area

Transitional Care Nurse / Case Manager Resume Examples & Samples

Oversees multiple health care center’s case management needs as assigned. Will average between 35 and 50 patients per week
Oversee the data collection process as needed by Payors, ACOs and bundled payments
Review the information and identify and highlight successes and identify and take action on areas needing improvement
Will be responsible for improving the Quality/Efficiency scores as deemed necessary to align with payor’s, ACO’s, and bundled providers requirements for participation
Responsible for the identification of opportunities and threats that may impact meeting payor’s/ACO’s Quality/Efficiency scores
Proactive post discharge follow-up; telephonically for a minimum of 30 days following discharge
Coordination of post discharge care with primary care physician or appropriate designee
Promote cost effective health care with aligned health system networks
Function as a member of a self directed team to meet specific individual and team performance metrics
Telephonic discussion with health care providers, managed care organizations, ACOs and defined referral sources to obtain and/or to explain benefit coverage determinations and to provide and/or obtain additional clinical information
Develop, implement and maintain systems, policies and procedures for the collection and analysis of performance metrics
Establish consistent reporting and review process to ensure effective communication and collaboration with Managed Care Organizations, ACOs, defined Referral Sources, , Medical Director and physicians as appropriate
Help patients and their families in obtaining referrals to a specific specialist
Review and ensures the appropriateness and adequacy of all therapy and clinical assessments of patients
Collaborates effectively with the patients health care team to establish an optimal cost effective plan while inpatient and transitioning to the next level. The health care team may include physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc
Consults with the Physician and health plan to resolve any barriers in the patient’s movement along the continuum of care
Completes daily review of census and prioritizes work in order to effectively manage assigned case load
Reviews with the ED and other key department’s monthly readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for improvement
Directs the Utilization Review meeting related to managed care, bundled payment and ACO patients weekly
Must have, as a minimum, two (2) year’s experience in a hospital, nursing care facility, or other related health care facility
Must have a working knowledge of managed care rules, regulations, and guidelines
Prior experience with a Health Plan, private or third party case management company preferred
Effective influencing, negotiation, relationship-building and communication skills are essential
Ability to work effectively under pressure, due to change of priorities
Ability to facilitate the integration of the clinical, finance, operations, and strategic functions of the organization
Possess strong leadership, critical-thinking and motivational skills/abilities
Ability to adapt quickly to changing conditions while managing multiple priorities
Ability to work effectively and establish and promote positive relationships

RN Nurse Case Manager Resume Examples & Samples

Conduct face-to-face initial assessments within 30 days of enrollment in MCO or admission to facility
Create patient-centered care plans yearly, revise quarterly, and as needed
Discharge planning and coordination
Monitor Skilled Nursing Facility (SNF) stay and assist with discharge planning
Conduct assessments and coordinate community transitions following the Money Follows the Person program which could include working with NF administrators, coordination of benefits, community home visits to determine home modification needs, and care team meetings
Present complex cases during Interdisciplinary Care Team meetings to gain insight from health services leadership, medical directors, pharmacists, co-workers, etc
Solid computer skills including the ability to document case notes using the case management system

RN Nurse Case Manager Hidalgo, Texas Resume Examples & Samples

Develop and implement alternative treatment plans that address individual needs of the member, their benefit plan, and community resources
Conduct face-to-face quarterly visits
Understand and follows policies and procedures and produces and submits reports in a timely manner

Transtar Nurse Case Manager Resume Examples & Samples

Manages all medical duties and responsibilities assigned to the Transtar IDM
Manages and arranges all medical examinations for the Transtar properties, which include: Pre-employment, Hearing conservation, Regulatory (FRA & DOT), Company, Return to work and Fitness for duty
Actively case manages all Transtar occupational and non-occupational injuries as well as the associated Salary Continuance, Wage Continuance, Sickness and Accident, or Supplemental Disability claims
Serves as the corporate medical liaison for Transtar IDM function, who manages and coordinates medical treatment with the various USS medical facilities as well as with other contract and non-contract providers
Serves as the corporate contact for the EAP program
Manages all Transtar Drug and Alcohol testing and assures that proper MRO review occurs. Assures that proper corporate designees (DER’s) are notified of test results and proper distribution of data occurs. Manages and secures all records pertaining to Drug and Alcohol testing and reviews the records with the MRO when needed
Works closely with corporate safety professional and maintains the occupational injury log and medical files. Oversees and manages injury information systematically, as appropriate, and participates in both company and regulatory audits
Consults with all Transtar departments (operational & administrative) relative to IDM policies and regulatory matters affecting their operations
Manages and administers all IDM policies and procedures and monitors corporate compliance
Consults and assists outside legal counsel with cases that are in litigation relative to medical issues
Manages and reviews all Transtar FMLA requests. Responds to requests regarding employees off for “serious health conditions”. Also reviews and consults with the Human Resources department relative to requests pertaining to “care of others” within the FMLA law
Consults with Company designated physicians in establishing three panel boards when required by law or labor agreement
Manages, reviews and maintains all policies and forms pertaining to IDM. Recommends changes to both policies and forms and is responsible for proper dissemination once they are approved
Assists the General Claim Agent in claims matters as directed
Minimum requirement - Bachelor’s Degree in nursing and at least 3 years of clinical practice
Ability to obtain licensure in each of the states Transtar operates is required; Certified Case Management (CCM) or Certified Disability Management Specialist (CDMS) certification is preferred

Nurse Case Manager Resume Examples & Samples

Responsibilities include collecting, analyzing, and evaluating clinical documentation received using established criteria to determine appropriateness of clinical decisions; Meet/exceed service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, Abandonment Rate)
Collaborates with the Medical Director to identify utilization trends and generation of monthly written reports
Process approval and adverse clinical determination correspondence for members related to Prospective request for services
Initiate the letter of agreement process, working with Network Management to ensure Service Level Agreements are completed in a timely manner when applicable
Proficient knowledge of Health Services policies and procedures, Medicare, HIPPA and NCQA standards
Professional demeanor and the ability to work effectively within a team or independently
Flexible with the ability to shift priorities when required
Coordinates with member, family, and caregivers to help resolve barriers to care

Nurse Case Manager Resume Examples & Samples

Responsible for providing medical and disability case management services, which includes review and evaluation of Workers' Comp. claims for vocational and/or medical service delivery
Must work collaboratively with claims staff, injured worker, employer and health professionals to promote quality medical care and timely Return-To-Work (RTW) to achieve optimum, cost-effective medical and vocational outcomes
Requires assessing, planning, implementing, coordinating, monitoring and evaluating medical services and RTW options
Responsible for early intervention for lost time cases that are not categorized as High Exposure
Strictly telephonic and will focus on disability and medical management activities that result in a timely and sustained RTW
The Case Manager will be involved in the early stages of the injury process
The Case Manager will handle between 75-85 cases with a moderate degree of complexity and acuity of medical condition
Candidates will be well versed with the RTW program and is highly involved with medical management
You will participate in round tables, coordinate services and ongoing treatment
This position requires a clinical background

RN Nurse Case Manager Resume Examples & Samples

Minimum 3 years RECENT clinical experience in an acute care case manager
InterQual experience required
Midas experience preferred
Experience working with a hybrid medical record
Critical thinking ability

RN Nurse Case Manager Resume Examples & Samples

Identifies customer needs, coordinates and support planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the alternative treatment plan. Conducts on-site evaluations (customer home visits) as is necessary
Documents all customer and provider contact, clinical notes, short term, long term and prioritize goals and revisions to the individual care plan in the integrated care management system
Develop and implement individual care plans with customer
Communicate care plan with customer and physician
Extends, revises or closes care plan goals as is appropriate
Refers questionable case management cases or requests to the Medical Director
Communicates in writing to the appropriate parties regarding case management decisions
Communicates denial decisions to all appropriate parties following established guidelines, when dealing with a denied authorizations such as, but not limited to, out-of-network referrals
Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care to the Manager of Quality Assurance
Attend and participate in weekly Complete Health Team rounds
Attends and actively participates in staff meetings
Current Licensure as a registered nurse, in the state of Texas in good standing

Home Health Nurse Case Manager Resume Examples & Samples

Associate Degree in nursing
Must possess the ability to effectively manage time and complete documentation on a tablet into an electronic patient record
Current Colorado State nurse license, valid Driver's license, proof of Motor vehicle insurance required
Wound care and/or IV certification
Bachelor’s of Science in Nursing for RNs
Would like to cross train in Hospice

Nurse Case Manager, or, Sacramento Resume Examples & Samples

Applicant must live in Sacramento and may be required to do field visits
Requires a current, unrestricted California RN license
Experience in Skilled nursing, Rehabilitation, or Home Health is preferred
Knowledge of community resources and programs such as CBAS, In Home Operations, In Home Supportive Services
Must have excellent PC skills (Word, Outlook, ability to navigate around the internet)
Must be organized, flexible and an independent worker

Telephonic Nurse Case Manager Resume Examples & Samples

Worker’s compensation or disability management experience
Proven experience in Nurse Case Management
Multi-state knowledge/experience is preferred
Ability to coordinate the individual’s treatment program while maximizing cost containment
Two to five years’ clinical experience is required. Experience in orthopedics, neurology, rehabilitation and/or internal medicine is preferred
Spanish speaking is a plus
Licenses or Certifications: All applicants must be a Licensed Nurse. CCM, COHN preferred or able to sit for exam within one year of employment
Must have direct internet access (i.e. cable, DSL). Wireless or satallite will not suffice

Senior Field Nurse Case Manager Resume Examples & Samples

Two to five years’ experience as a field case manager
Spanish speaking a plus
Requires valid driver's license

Workers Compensation Telephonic Nurse Case Manager Resume Examples & Samples

Performs initial evaluation assessment via telephone calls to the injured worker, employer (when requested) and healthcare provider within two (2) business days of case management referral
Evaluates need for alternative treatment
Facilitates authorized treatment utilizing contracted networks
Negotiates level of care, intensity and disability duration with providers
Negotiates and coordinates a prompt return to work with employer
Adheres to quality assurance standards and department processes
Provides case direction and supervision to field case specialists when on-site intervention is required; ensures quality and appropriate service delivery
Communicates effectively with claims adjuster, claimant, employer and healthcare provider
Utilizes national evidence based guidelines and the peer review process
Adheres to the utilization review process
Adheres to state statute concerning time frames for medical care and appointments
Follows company policies governing the Case management/ workers comp process
Regular reporting to management on case management status
Ability to analyze and interpret medical data
High level knowledge of the worker’s compensation industry and claims processes, reporting and regulatory requirements
Good research and investigation skills
Ability to clearly express and synthesize case facts, decisions and rationale
Good written and verbal communication skills
Good interpersonal skills with a diverse group of contacts
Maintains confidentiality as well as a high degree of professional integrity
Ability to provide a high level of customer service while working in a fast-paced environment
Demonstrated attention to detail with good organizational and prioritization skills
Ability to work well within a team environment and facilitate the team concept
Ability to understand and work within the claims environment
Individual should be proficient using Internet software, and Microsoft applications including Word, Excel and Outlook
Ability to learn other computer systems used in the case management process
Registered Nurse with degree from an accredited college or university
A minimum of five (5) years clinical work experience preferred
One year minimum experience in workers’ compensation case management (with carrier / TPA or independent case management company and may be either field or telephonic in nature). Alternately, experience in either an employer-based, industrial workers compensation nurse role, or a facility case manager role may be considered

Contract Nurse Case Manager Resume Examples & Samples

Telephone support (including maintenance calls and adherence support)
Work directly with the reimbursement specialist and the physician to secure funding for their patient’s therapies; assist with alternative funding searches when needed
Attend pharmaceutical sales meetings as required
Attend patient meetings, conferences as needed to educate patients, providers regarding disease/product information and case management services
Work with patient associations and advocacy groups
Establish and maintain partnerships with pharmaceutical team
Liaise with health care providers, pharmacies and infusion clinics, and other agencies as required, to coordinate infusions, drug delivery and resolve issues as they arise
Clear communication to the manager, team and the client regarding the management of patient cases
Experience with oncology is an asset
Strong phone etiquette
Ability to communicate and comprehend medical information
Ability to work autonomously

Pediatrics Nurse Case Manager Resume Examples & Samples

Current, unrestricted RN license in Maryland required
Strongly prefer Pediatrics experience
Prefer bilingual Spanish speaker

RN Nurse Case Manager Harlingen, Texas Resume Examples & Samples

Maintains physical presence in participating provider practices
Identifies high-risk/high-cost patients for possible case management intervention
Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning, and alternative treatment plan development
Collaborates with the attending physician to achieve identified patient outcomes
Perform telephonic outreach or home visits, as needed
Communicates with all departments to resolve issues or document trends
Understands and follows administrative guidelines (policy and procedure) of the unit
Basic Mathematical and statistical ability
Typing and computer knowledge- able to type 35WPM
Knowledge of utilization review requirements and procedures
Knowledge of current health care practices and appropriate treatments
Ability to travel to and work at participating provider offices
Bilingual – preferred Spanish both conversational and written
Associates degree, diploma or B.S. in Nursing
Five (5) years recent experience in an acute-care environment, or
Two years (2) years recent experience in a case-management or utilization management position

RN Nurse Case Manager Resume Examples & Samples

Responsible for coordinate and manage relationships with participating provider practices
Coordinate effective, efficient & proactive completion of all utilization management activities that facilitate the member’s movement through the continuum of care
Utilization Management Responsibilities
Performs all utilization review activities according to Health Services policy and procedures. Conducts onsite/telephonic review as assigned to obtain required information
Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelines
Facilitates the movement of the member through the continuum of care in a proactive manner
Refers cases to the Medical Director/POD Medical Director as appropriate
Concurrently enters all information into the healthplan’s computer documentation system ensuring complete and accurate information per established policies and guidelines
Notifies hospital and/or providers of all denials and generates denial letters as directed by the Medical Director within assigned time frames
Participates in education of providers regarding Health Services policies and procedures
Maintains strong working relations with internal and external customers. Presents all communication in a positive and professional manor
Attends and actively participates in staff meetings and is responsible for reviewing information presented
Actively participates in identification of opportunities for improvement and assists with action plan development and problem resolution
Knowledgeable in workflow, productivity and timeliness standards for all programs services
Completes and meets minimal IRR and audit standards
Attends and actively participates in assigned POD Inpatient Manager Meetings as scheduled
Available and responsive to health plan and facility partners during regularly scheduled business hours
Supports an environment which fosters teamwork, cooperation, respect, and diversity. Establishes and maintains positive communication and professional demeanor with coworkers, delegates, vendors and members at all times. Demonstrates and supports commitment to organizational and plan goals and objectives
Embedded Care Coordinator Responsibilities
Identifies gaps in needed quality metrics for customers and communicates to provider
Identifies customer needs, coordinates and supports planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
Maintains all necessary educational requirements for required licensure and certifications
General Responbilities
Performs other related duties and projects as assigned
Adheres to Organizational policies and procedures
Verbal and written communication skills - Written and oral communication is accurate and timely and at the appropriate level
Ability to articulate clinical and non-clinical information to personnel/members at all levels of understanding
Assists in the education of internal and external staff in operations, policies and procedures, and regulatory standards
Demonstrates critical thinking and problem solving skills
Knowledge of health insurance industry and processes
Detail oriented, highly self-motivated, responsive and dependable
Team and goal oriented
Basic knowledge of mainframe/PC systems and keyboarding skills
Works independently with minimum of supervision
Knowledge of ICD-10 coding, CPT coding and Interqual guidelines for utilization review
Current Driver’s license with current auto insurance

Nurse Case Manager Resume Examples & Samples

Negotiates fees with vocational rehabilitation, medical case management and DME vendors
Coordinates and monitors referrals to rehabilitation and medical case management vendors
Coordinates services as indicated with HIG Utilization Review department nursing staff
Gathers, compiles, analyzes and reports service data significant to clients
Acts as resource to claims professionals, underwriting and account representatives for identification of appropriate medical services, goods and providers

Inpatient Nurse Case Manager Resume Examples & Samples

Three to five years clinical practice experience and 2 years case management experience required
May require experience with short or long term disability and knowledge of workers' compensation regulations
Excellent time management, organization and negotiation skills
Ability to assess complex issues, recommend changes and resolve problems. Knowledge of managed care preferred
Works independently, receiving direction from manager for new or unprecedented situations
Manages own caseload and coordinates all assigned cases

Workers Compensation Nurse Case Manager Resume Examples & Samples

Establish and maintain communications with attending physicians, claims adjusters, injured workers and employer
Update adjuster, client and injured worker in timely and professional manner
Schedule and precertify all necessary medical appointments with providers and ancillary services
Transcribe, document and maintain employee medical history in the WC system using approved format
Attend Team Meetings and Case Management meeting as scheduled
Review requests for specialty services and direct IN Network when available (define service to be provided; research network providers; direct patients accordingly)
Monitor and track Disability Management and Plans on all cases
Maintain and update Case Review diary/note on all cases
Responsibilities may vary dependent upon specific client requirements
3 – 5 years clinical practice experience, Computer Skills, keyboard knowledge, Microsoft Office; Word, Excel

Nurse Case Manager Resume Examples & Samples

Establishes a collaborative relationship with member, family, physician(s), and other providers to determine medical history along with current status to assess the options for optimal outcomes
Implements, coordinates, monitors, and evaluates the case management plan on an ongoing, appropriate basis
Adheres to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures
Demonstrates sensitivity to culturally diverse situations, members, and clients
Utilizes effective communication, courtesy, and professionalism in all interactions, both internally and externally. Assists and supports other departments as required
Provides service delivery on assigned products in a manner consistent with established standard policies/procedures and customer result expectations. Requires performance on such things as

Rn-nurse Case Manager Resume Examples & Samples

Requires a Bachelor's degree in a health related field
3 or more years of clinical experience; or any combination of education and experience, which would provide an equivalent background
Current, unrestricted DC RN license is required
Medicaid and/or managed care experience preferred but not required

Field Nurse Case Manager Resume Examples & Samples

Must have excellent time management and organizational skills
Written Abilities: Proficient grammar, sentence structure and written communication skills are required
Technical Experience: Knowledge of basic computer skills including Excel, Word, and Outlook Email is required. You will also need direct access to the internet
Licenses or Certifications: Current, unencumbered Registered Nurse license in the resident state; CCM, COHN preferred, or able to sit for exam within one year of employment. Must have reliable transportation M-F, 8am-5pm Pacific Time. Must have local unencumbered driver’s license and proof of automobile insurance

Nurse Case Manager Resume Examples & Samples

Experience with making diagnoses and choosing, initiating, and modifying selected therapies to assist patients with optimizing their level of function and self-care
Knowledge of patient education principles and the management of complex medical, psychosocial, and financial problems to enhance patient adherence to individualized treatment plans and train peers and staff
Ability to seek feedback from peers, professional colleagues, clients, and research outcomes to expand clinical knowledge, enhance role performance, and increase knowledge of professional issues
Ability to obtain a security clearance
Ability to consult with healthcare providers at all levels and negotiate with outside providers for services and products to obtain client services and support
Secret clearance

Nurse Case Manager Resume Examples & Samples

Coordination of care occurs with member’s Primary Care Physician, member is scheduled for and receives f/u appointment within 7 days of discharge
Member has safety equipment and resources to achieve the highest level of health outside of the inpatient setting
Member understands medications and knows how to acquire them after hospital discharge
Member receives services to meet ongoing needs

RN Telephonic Nurse Case Manager Resume Examples & Samples

Obtains informed verbal consent and takes all steps to obtain written consent, as appropriate
Assists the member in setting short term and long term goals, time frames for follow up, resources available (internal and community), involves all appropriate parties (member, physician, providers, employer, family, etc) and identifies anticipated case results/outcomes and criteria for case closure
Delivers utilization review services when member is in active case management as appropriate
Participates in departmental and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate

RN Nurse Case Manager, Workers Compensation Resume Examples & Samples

Perform prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals and select outpatient services
Attend Field Case Management visits when necessary
Monitor Time Management when it applies to a client

RN / Reigstered Nurse Case Manager PRN Resume Examples & Samples

Completes continued stay reviews and submits to private payers to ensure patient continues to meet inpatient admission criteria
Performs continuous assessments and evaluations to ensure patient is progressing towards desired outcomes
Reviews metrics reporting data and make corrections according to CMS and HCA guidelines
Ensure Medicare Order Form on chart, documented and authenticated
Assesses and responds to patient/family needs by coordinating efforts of other team members
Identifies and resolves barriers that hinder effective patient care
Collaborates and consults with physicians on patient’s progress and discharge planning needs
Coordinates the discharge planning process ensuring involvement of all members of the healthcare team. Counsels with patient and family members for decision making and in meeting psycho-social needs of patient
Maintains knowledge of resources and facilities available to patients and family members
Collaborates with personnel at other facilities to coordinate smooth and effective patient transfers and transitions

Rn-nurse Case Manager Resume Examples & Samples

Current, unrestricted RN license in the state of NJ required
Requires 5 years of clinical experience; at least 1 year in a Nurse Care Manager I role or equivalent experience; or any combination of education and experience, which would provide an equivalent background
Prefer experience performing assessments on members in a health insurance company
Must be organized, self-motivated, and detail oriented
Must be able to sit and speak with people on the phone for extended periods of time

Nurse Case Manager Rn-field Based & Telephonic Resume Examples & Samples

Visit Medicare members in their homes and/or other settings, including community centers, hospitals or providers' offices
Help members understand their benefits
Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction
Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels
Assist members with the transition from a care facility back to their home
Current, unrestricted RN license in the state of Alabama
Ability to travel to member homes or other locations within the greater Jefferson County, AL area
3+ years RN nursing experience in a hospital, acute care, home health/hospice, direct care or case management
Must live within a commutable distance (50 minutes or 50 miles) of the greater Jefferson County, AL area
CCM / Certification in Case Management

Behavioral Health Nurse Case Manager Resume Examples & Samples

Support the mental and physical health care of patients on an assigned patient caseload. Closely coordinate care with the patient’s medical provider and, when appropriate, other mental health providers
Screen and assess patients for common mental health and substance abuse disorders. Facilitate patient engagement and follow-up care
Provide patient education about common mental health and substance abuse disorders and the available treatment options
Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications
Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment
Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate
Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated
Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s medical provider. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case reviews may be conducted by telephone, video, or in person and may include members of Monarch’s clinical care team
Track patient follow up and clinical outcomes using an electronic system. Document in-person and telephone encounters using the system to identify and re-engage patients. Such registry functions can be accomplished through an existing software system, EHR build, on a spreadsheet used in conjunction with an EHR, or can be built into a stand-alone clinical management tracking system that may or may not be linked to an EHR
Document patient progress and treatment recommendations in an electronic system and other required systems so as to be shared with medical providers, psychiatric consultant, the Monarch clinical team and other treating providers
Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care
Facilitate referrals for clinically indicated services under the behavioral health benefit (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment)
Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload
Works collaboratively with members of the Monarch clinical team which may include a nurse case manager, pharmacist, social worker, disease management team and palliative care team to coordinate behavioral and medical needs
Facilitate referrals for clinically indicated services under the patient’s medical benefit
Current, unrestricted RN license for state of CA
3+ years of Behavioral Health Nursing experience
Ability to adapt to a quickly changing work environment
Ability travel within Orange County, CA
CCM - Certified Case Manager
Addiction medicine expertise
Ability to maintain effective and professional relationships with patient and other members of the care team
Experience with screening for common mental health and/or substance abuse disorders
Working knowledge of differential diagnosis of common mental health and/or substance abuse disorders
Ability to effectively engage patients in a therapeutic relationship
Ability to work with patients by telephone as well as in person
Experience with assessment and treatment planning for common mental health and/or substance use disorders
Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions for common mental health disorders, when appropriate (e.g., motivational interviewing, problem-solving treatment, behavioral activation)
Basic knowledge of psychopharmacology for common mental health disorders that is within appropriate scope of practice for type of provider filling role
Experience with evidence-based counseling techniques

Telephonic Nicu Nurse Case Manager Rn-missouri Resume Examples & Samples

Effectively using established operating systems to document activities and ensure consistent program clinical practices
Collaborating with hospital staff and other clinical programs to enhance the quality and efficiency in healthcare delivery
Interacting with Medical Directors on challenging cases
Coordinating services as needed (home health, DME, etc.)
3+ years of High Risk Level II or Level III NICU care experience
Superior communication skills
Proficiency utilizing Microsoft Word, with the ability to navigate a Windows environment
Must reside in state of Missouri
Case Management experience is strongly preferred
Experience in utilization review, concurrent review and/or risk management

Nurse Case Manager, Supervisor Resume Examples & Samples

Knowledge of disease specific states, clinical and community resources
Ability to network, advocate, communicate assertively with all stakeholders
Minimum Education: RN or LVN or LPN with active licensure status in the applicable state/s
Minimum Experience

Nurse Case Manager Resume Examples & Samples

Communicate patient progress and continued needs with family/guardian/referral source and payer source
Ensure coordinated, effective patient care by managing timely transitions through the phases of rehab
Ensure continued availability (recertification) of financial resources throughout the patient's hospitalization
Facilitate treatment team reviews and its documentation
Basic understanding of and comfort level with medical terminology, rehabilitation treatment, clinical science/pathology and psychiatric disorders
Must be articulate, assertive, and able to communicate effectively with families, payers, therapists and physicians both verbally and in writing
Must be able to acquire clear understanding of treatment priorities and ability to make sound decisions balancing patient and family needs with available resources

RN Nurse Case Manager Mcallen, Texas Resume Examples & Samples

Develops, monitors, and evaluates the plan of care, extends, revises or closes the plan of care according to Interdisciplinary care team recommendations and communicates case management decisions
Perform research on relevant topics in health promotion and disease prevention, as required for specific members or as part of ongoing team education as requested
Understands and follows policies and procedures, completes documentation of interactions and interventions of assigned members in the QNXT case record or other systems as it applies, produces and submit reports in a timely manner and in accordance with workflows and policies
Actively participates in interdisciplinary care teams; assures appropriate documentation in QNXT and defined care plans are completed

Nurse Case Manager Rn-field Based & Telephonic Resume Examples & Samples

Visit Medicaid and Dual SNP members in their homes and/or other settings, including community centers, hospitals or providers' offices
Current, unrestricted RN license in the state of Washington
Ability to travel to member homes or other locations within the greater Seattle, WA area
Must live within a commutable distance (50 minutes or 50 miles) of the greater Seattle, WA area
Experience working with High Risk patients
Experience working in a Med Surg environment

Telephonic Nurse Case Manager Resume Examples & Samples

Performs medical cost projections for claims examiners, when requested
Adheres to URAC standards
Serves as an informational and medical resource for the claims administration staff
2-3 yrs direct clinical patient care with experience in orthopedic, neurological, rehabilitation, medical/surgical or occupational health
Excellent keyboard and PC automation skills
Certification: CCM, CDMS, CRRN, COHN

Nurse Case Manager Resume Examples & Samples

Performs a critical review and analysis of medical information with regard to diagnosis, treatment, prognosis and duration of the conditions, forms a conclusion, and clearly communicates the rationale
Completes written and verbal consultations with all levels of the claims staff that will clearly outline the answers on functional parameters as well as the length and severity of the medical condition(s)
Participates in consultation meetings with claims staff regarding disability claims, capturing essential elements of a file
Ensures quality investigations of medical information utilizing the resources available
Assists with determining the need for Independent Medical Examination (IME) reports, Peer Reviews, or Functional Capacity Evaluation (FCE) reports
Helps claims staff increase knowledge of medical terminology and conditions through training and feedback
Assists with the development of return to work plans
Maintains knowledge and skills regarding medical advances and communicates/educates claims staff in one on one meetings
Continues to research rare/unusual medical conditions and be knowledgeable on the tools necessary to perform this research
Communicates verbally and in writing with providers, subscribers and other appropriate contacts in a professional and effective manner, resolving discrepancies and clarifying medical information, including diagnosis, treatment, prognosis, restrictions, limitations, and duration of conditions
Participates in triage and multi-disciplinary roundtable sessions to provide expertise on medical issues
Maintains RN license
Conducts in-service training for claims staff on various medical conditions and treatment
Participates in industry meetings
Current and valid Registered Nurse license
AA or Nursing Diploma required; BSN, BA or BS preferred
Minimum 3 years of clinical experience required
Strong knowledge of medical treatment protocols
Experience in utilization review/health care industry insurance preferred
Strong research, analytical, critical thinking, problem solving and decision-making skills
Ability and desire to work in a fast-paced, service-oriented environment
Excellent verbal communication skills, with the ability to be both pleasant and professional
Strong written communication skills
Ability to work well independently and in a team environment
Ability to initiate and prioritize regular work duties and projects
Detail oriented, organized, the ability to multi-task, and strong time management skills
Strong computer skills, proficient in PC environment and MS Word, Excel, and email systems
Ability to work professionally and effectively with co-workers, clients, claimants, vendors and others with whom Sun Life does business

Nurse Case Manager Rn-medicaid Resume Examples & Samples

Make outbound calls to assess members' current health status
Identify gaps or barriers in treatment plans
Provide patient education to assist with self management
Interact with Medical Directors on challenging cases
Coordinate care for members
Make referrals to outside sources
Coordinate services as needed (home health, DME, etc.)
Educate members on disease processes
Encourage members to make healthy lifestyle changes
Document and track findings
Utilize Milliman criteria to determine if patients are in the correct hospital setting
Make “welcome home” calls to ensure that discharged member receive the necessary services and resources
Possible hospital visits with members
Required to operate multiple software programs and platforms simultaneously
Current, unrestricted RN license in the state of Arizona
Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses
Reside in the state of Arizona
Ability to travel to member homes or other locations within service delivery area as applicable (50 miles or 50 minutes of your home)
3+ years RN nurse clinical experience in a hospital, acute care, home health / hospice, direct care or case management
Computer / typing proficiency to enter/retrieve data in electronic clinical records; experience with email, Internet research, use of online calendars and other software applications
Willingness to obtain Certified Case Manager (CCM) certificate within 30 months of employment if you do not already have it
Certification in Case Management - CCM
HIV/AIDS disease management experience
Experience working with Behavioral Health population consisting of substance abuse, addictions, mental illness, etc
Home care / field based case management
Medicaid or Managed Care experience
Experience in Home & Community based or Long Term Care services delivery

Telephonic Nurse Case Manager Rn-telecommute From Michigan Resume Examples & Samples

Current, unrestricted RN license in Michigan
3+ years RN / nursing experience in a hospital, acute care, home health/hospice, direct care or case management
Computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications
Must reside in state of Michigan
Access to high speed internet from home
Dedicated work space from home
Certified Case Management (CCM)
Med surg experience
Medicaid, Medicare, Managed Care experience

Nurse Case Manager RN Resume Examples & Samples

Coordinates services and referrals to health programs
Identifies problems or gaps in care offering opportunity for intervention
Assists members in sorting through their benefits and making choices
Takes in - bound calls and places out - bound calls as dictated by consumer and business needs
Special projects, initiatives, and other job duties as assigned
Current, unrestricted RN licensure
3+ years of Clinical RN experience
Intermediate computer skills (Microsoft Word, Outlook and Internet) with the ability to navigate a Windows environment and the ability to create, edit, save and send documents utilizing Microsoft Word
Coaching and / or decision support experience
Strong inbound and outbound telephonic skills
Understanding of change and ability to move members along the continuum of change
Intermediate or expert level of proficiency with being able to assess and identify needs and being able to influence and motivate
Conflict management skills
Able to work under pressure and appropriately prioritize responsibilities

Nurse Case Manager Resume Examples & Samples

Refer high risk customers to case management
Identify and address customer gaps in care, which may include primary care physician
Disease management education for chronic illnesses including diabetes, hypertension, COPD and others
8:00am-5:00pm Monday – Friday
Active RN License in the state of Tennessee
3 years clinical practice experience
2+ years’ experience in Case Management preferred

Nurse Case Manager Rn-field & Telephonic Resume Examples & Samples

Interacting with Medical Directors on challenging case
Coordinating services as needed (home health, DME, etc)
Occasional field visits to members
Current, unrestricted RN license in the State of Delaware
3+ years’ experience in a hospital setting, acute care, direct care experience as an RN and/or experience as a telephonic Case Manager for an insurance company
Computer proficiency utilizing MS Office (Word, Excel, PowerPoint and Outlook), including the ability to type and talk at the same time while navigating a Windows environment
Strong Pediatrics and Adult clinical background
Experience working with special needs population
Reside in the greater New Castle County, DE area
Experience working in Psychiatric care
Behavioral Health Experience
Experience working in Substance Abuse
Medicaid Experience

Nurse Case Manager Resume Examples & Samples

3 years of acute care clinical experience
Condition-specific clinical experience
Home health/discharge planning experience
Patient-oriented approach

Telephonic Nurse Case Manager Resume Examples & Samples

R.N. (Registered Nurse) required
6 or more years of related experience, including Case Management experience
Bill Review experience

Nurse Case Manager Resume Examples & Samples

Review analyzes of activities, costs, operations and forecast data to determine progress
Develop, implement and maintain compliance with policies and procedures regarding medical case management programs to facilitate the use of appropriate medical resources and decrease health plan financial exposure
Promote compliance with Federal and State Regulations
Bachelor’s degree in Nursing or equivalent experience
3+ years of case management experience and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience
Thorough knowledge case and/or utilization management and clinical nursing
Familiarity with Medicaid managed care practices and policies
Unrestricted RN license in TX

Workers Compensation Solution Nurse Case Manager Resume Examples & Samples

Education: Registered Nurse licensure
Experience: Previous workers’ compensation and/or disability case management experience or Occupational health experience
Abilities: flexibility, customer focus, creativity and innovation, continuous learning. Maintain reasonable and predictable work attendance
Skilled in: personal leadership, relationship building, problem solving, planning and organization, conflict resolution, accountability, persuading and influencing

Nurse Case Manager Specialist Resume Examples & Samples

Education around the best practices through to all stage of diagnosis
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
Build solid working relationships with client team, internal staff, matrix partners, key functional areas, customers, and providers
Based on experience, may provide leadership, preceptor/mentorship, support and coverage to other case management staff and assist case managers in achieving positive outcomes and savings
Triggers and works in partnership with Care Allies for specific case management needs
Ability to read and write Arabic & English required for this position
Active RN licensure with no restrictions or stipulations in state of residence

Nurse Case Manager Resume Examples & Samples

Conducts concurrent daily chart review, investigating patient history, symptoms, clinical status, and treatment utilizing Interqual ISD criteria as a tool to determine a patient's severity of illness and the intensity of service
Works with multidisciplinary team to develop treatment plans, including contingency plans
Leads daily case management rounds on assigned unit. Participates in house staff rounds
Provides necessary information to appropriate organization to obtain continued stay certification; assesses payers' and referring physicians' needs in regard to content and frequency of communications
Facilitates early referrals to social work, rehab services, patient advocacy, and quality management as needed
Associate's degree required in Nursing. Bachelor's degree preferred in Nursing
License required: Nursing License
Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases
Previous clinical nursing experience and/or case management experience

Nurse Case Manager Resume Examples & Samples

Currently employed Licensed Practical Nurse case manager with equivalent experience and Georgia license
5 years of broad clinical experience, predominantly in pediatric care
Experience in care coordination, case management, discharge planning, and utilization review
Excellent communication skills, both verbal and written
Effective decision making/problem-solving skills and demonstration of creativity in problem-solving
Influential leadership skills
Demonstrated effective critical thinking skills and ability to anticipate patient discharge needs
Moderate to expert computer skills
Completes initial screen of all patients on admission (not to exceed within 24 hours of admission) utilizing specific trigger criteria to identify needs related to care coordination and/or discharge planning
Develops, initiates, and implements a robust transition care plan in collaboration with clinical team for all applicable patients
Cultivates and maintains effective interaction/communication with members of medical staff, nursing staff, social workers, and others to drive care coordination process and facilitate continuity of patient care
Communicates with all members of multidisciplinary team to facilitate care coordination process for assigned workload
Communicates with home health agencies, third-party payors, and other community resources as needed to coordinate discharge needs
Facilitates and provides ongoing communication with patient/family and interdisciplinary staff to identify and resolve potential barriers
Facilitates care conferences, interdisciplinary rounds, and other meetings
Participates in focused system initiatives and facilitates clinical practice guidelines at the patient level
Performs outpatient and clinic care coordination and monitors care as patients transition between outpatient and inpatient services where appropriate
Refers cases identified as risk management, peer review, or quality issues to appropriate personnel
Performs other responsibilities as required

Nurse Case Manager Resume Examples & Samples

Must demonstrate knowledge needed to provide age-appropriate nursing and case management skills
Must be proficient on all Microsoft Office applications
Must be able to follow patient safety and confidentiality (HIPAA) guidelines

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Nurse Case Manager Resume Examples & Samples

Planning and Implementation. Develops and implements action-oriented and time specific case management plans by determining and documenting specific objectives, goals, and actions designed to meet the client’s health and human service needs identified through the assessment process. Coordination.Organizes, secures, integrates, modifies, and documents the resources necessary to accomplish the goals set forth in the case management plan
Monitoring and Evaluation. Gathers information and documentation from all relevant sources regarding the case management plan’s activities and/or services to determine the plan’s effectiveness in reaching desired outcomes and goals. Modifies or changes the case management plan, as needed
Outcomes. Measures and analyzes the interventions to determine the outcomes of case management involvement, e.g. clinical, financial, variance, quality/quality of life, client satisfaction
As Needed. Performs other duties as needed to successfully fulfill the function of the position, including but not limited to orienting and educating consumers, maintaining records of service delivery, serving as liaison between the program and other agencies, conducting quality improvement audits, and report preparation

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Eh-nurse Case Manager Resume Examples & Samples

Assesses or prescreens all patients for Case Management services. In addition; referrals are received from physician orders; nursing orders; and multidisciplinary rounds
Develops needs and prioritizes with input from all parties to organize a plan that will provide maximal outcomes
Serves as a liaison among the patient; family members; physicians; nurse; social worker; UR nurse; insurance representative and community resources to individualize patient care and outcomes
Advocates for services and funding necessary to meet established outcomes and maintains a working knowledge of the requirements of payers
Evaluates individualized patient outcomes and reassesses and adjusts plan to ensure quality and cost effective outcomes are met
Works in close collaboration with Social Work. Reviews cases with social work team members to establish and review plan of care

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Nicu Nurse Case Manager RN Resume Examples & Samples

Educating and supporting the family unit through telephonic assessment and expert clinical interventions
Evaluating delays in care, facilitating discharge planning, and arranging for alternative care services to facilitate timely and appropriate discharge
Documenting and tracking findings
Must reside in state of Texas
Experience/exposure with discharge planning

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Nurse Case Manager Resume Examples & Samples

Performs initial and ongoing clinical assessment via telephone calls to client (injured employee), employer, physician and attorney as indicated; assesses client's situation for psychosocial needs, cultural implications and support systems in place
Creates a case management plan based on the assessment with measurable goals and objectives utilizing evidence-based criteria; monitors ongoing progress toward these goals and objectives; implements plan through case management interventions and communication with all parties to reach desired goals and objectives
Negotiates appropriate level and intensity of care and disability duration with providers through use of medical and disability duration guidelines, adhering to quality assurance standards,
Measures interventions to determine the outcome of the case manager's involvement to include clinical, financial, variance, quality of life, and client satisfaction; maintains accurate record of management including costs, savings and demographic data
Communicates effectively with handling claims examiner, client, claimant, attorney and supervisor
Maintains client's privacy and confidentiality, promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards
Supports the organization's quality program(s)
Knowledge of workers' compensation laws and regulations
PC literate, including Microsoft Office products
Leadership/management/motivational skills
Excellent negotiation skills
Ability to meet or exceed Performance Competencies

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Nurse Case Manager Resume Examples & Samples

Bachelor's Degree is required, preferably in Nursing
Current Basic Life Support Healthcare Provider (American Heart Association) certification required
Minimum of three years of direct nursing experience and demonstrated clinical competence required

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Nurse Case Manager Emergency Room Resume Examples & Samples

Current Georgia Registered (RN) license
Experience in Case Management preferred
Knowledge of age specific needs of population served

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Nurse Case Manager Resume Examples & Samples

Minimum of three years of direct nursing experience and demonstrated clinical competence is required
Experience in Case Management is preferred
Current Georgia Registered Nurse (RN) license is required
Current Basic Life Support (BLS) certification is required

107

Nurse Case Manager, Oncology Resume Examples & Samples

One year of relevant experience
Must be able to work in a stressful environment and take appropriate action
Basic computer knowledge
Utilization Management and Care Coordination experience preferred

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Nurse Case Manager Resume Examples & Samples

You’ll act as a medical consultant for our internal claims department team members, providing case management services that promote employees in their return to work. You will work with customers and physicians all over the country and grow your knowledge and skills along the way. With a focus on promoting suitable care and successful return to work plans, you’ll advocate for the employee and communicate with a wide variety of people including the employee and their family members, treating and consulting physicians, and employer group representatives
You’ll review medical record documentation so that you can assess and evaluate medical conditions and history, diagnostic/test results and treatment. You’ll evaluate functional capacity with an eye towards appropriateness of care as well as expected duration of medical leaves. You’ll resolve inconsistencies between medical documentation and stated limitations
You’ll also collaborate with vocational team members to recommend job site modifications and safety or procedural changes. In addition, you may also be involved with developing and conducting medical education and training for internal claims department team members
A high sense of urgency with a focus on the customer and a desire to perform effectively to meet your individual and organizational goals
Strong analytical skills in order to identify and resolve issues effectively and independently
Clear and persuasive expression of ideas in both written and verbal communication
Desire and ability to collaborate with team members and facilitate discussions effectively
Ability to use computer software applications for reviewing and documenting customer claim files
Ability to shift priorities to meet demands from various customer groups
While not required, it’s a plus if you have a working knowledge of: ergonomics and assistive devices needed by people with disabilities and federal and state laws concerning leaves and disabilities e.g. The Americans with Disabilities Act (ADA), Family Medical Leave Act (FMLA), Fair Claims Settlement Practices Act, and health privacy laws e.g. (HIPPA)
You’ll have a minimum of 4 years hospital or clinical experience in relevant medical fields (e.g. cardiology, orthopedics, rheumatology, occupational medicine, or obstetrics), utilization review or quality management, or the equivalent combination of education and/or relevant experience

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RN Field Nurse Case Manager Resume Examples & Samples

Collaborates with hospitals discharge case managers to facilitate effective communication for discharge planning and transitions of care for the purposes of assisting with community resources, DME providers, referrals, housing and other related duties
Identifies barriers to care and intervenes appropriately to lessen or eliminate the barriers to care
As the members risk level improves, provides a current plan of care and reviews it with the appropriate SDA DM RN/LVN to transition the member for less frequent outreach also providing the LVN with signs and symptoms to watch for that would indicate escalation of condition that would require physician intervention
Consult with BH team members when the member’s behavioral health or emotional issues are impacting their ability to set and/or achieve goals

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Nurse Case Manager Resume Examples & Samples

Perform clinical services and direct nursing care, consistent with scope of State Nurse Practice Acts
Assist with ensuring mandated programs are completed to comply with regulations
Assist with planning, developing and implementing health and wellness (well-being) promotion programs
Actively participate in work teams and committees
Assist with managing inventory for medical supplies to include ordering and stocking
Assist with gathering of data for all required program reporting
Collaborate with employees, medical personnel, Management, Safety, Human Resources, Benefits and Legal to monitor, process and guide decision making on all accommodation requests. Engage in interactive process with employees for employment-related accommodations, including the benefits and privileges of employment
Review and analyze medical documentation to determine eligibility for requested disability-related accommodations including, but not limited to, requests for workplace modifications to assist employees to perform their essential job duties, changes in jobs and/or reassignment, and other potential accommodations to address disability-related limitations
Collaborates with company diversity officer, human resources, and workers compensation administrators to provide consultation, education and training on accommodation processes and the intersections of ADA, FMLA, Workers Compensation and other related laws and regulations
Serves as a case manager for cases where any combination of FMLA, Workers Compensation and ADA intersect; works closely with department managers and other involved constituents to ensure timely and complete resolution to cases
Tracking and reporting of overall case management metrics
Documenting and reporting all case activity for accurate case management
Maintain contact (phone, electronic, written) with all parties involved to monitor, update and advance case activity to ensure the progress of the case
Adhere to applicable laws, regulations and employer policies concerning confidentiality, privacy and protection of medical information
Other nursing duties/task as assigned
Perform all activities in a safe and responsible manner and support all Environmental, Health, Safety & Security requirements and programs
Actively participate in continuous improvement processes, learning and skills development
BS/BA in Nursing or Associates Degree in Nursing from accredited school. CCM, COHN or other related designation
Minimum of 5 years of experience working in case management
Travel between GLOBALFOUNDRIES manufacturing sites, Burlington, VT & East Fishkill, NY up to 10%
Master’s Degree in Nursing from accredited school
CCM, COHN or other related certification
6+ years of experience in Nurse Case Management, with a focus in work place, Occupational Health
Competency in case management process (including assessment, problem identification, outcome identification, planning, monitoring and evaluating)
Knowledge and understanding of the application of Section 503, 504 and the ADA in the employment context and ability to recognize risk associated with disability, employment and accommodation issues
Ability to interpret medical documentation to determine reasonable worksite or job-related accommodations
Workers’ Compensation-related experience desired
Excellent interpersonal skills and phone manners
Proficient in Microsoft Office suite as well as Google program
Ability to learn and attain proficiency with other company specific software programs
Ability to set priorities and work independently
Ability to work a variable work schedule to accommodate a 24/7 manufacturing setting

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RN Nurse Case Manager Resume Examples & Samples

2 year, $10,000 Commitment Bonus
Minimum 5 years recent clinical experience in an acute care setting
3 years acute care case management / and or utilization management / utilization review experience preferred
Able to type and navigate computer programs proficiently
Excellent organization, communication and time management skills

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Telephonic Nicu Nurse Case Manager Rn-telecommute Resume Examples & Samples

Utilize holistic approaches to patient care and integrates patient's life and motivational goals into the treatment plan
Provide education, information, direction, and support related to care goals of patients
Communicate with patients, families, caregivers, physicians, and other service providers to coordinate the care needs for the patient
Maintain a focus on the customer service through policy and program decisions and consider impact of these activities on the members
Promotes cost efficient health care consistent with adding value for consumers, customers and business
3+ years of hands-on clinical RN experience in a hospital, acute care, inpatient, home health/hospice or direct care environment
Willingness to obtain NCQA approved Case Management Certification (CCM) within 30 months of assuming the position for those who are not currently CCM certified
Experience in Managed Care
Home Health experience
NICU experience
Pediatrics experience

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Telephonic Complex Nurse Case Manager Rn-telecommute Resume Examples & Samples

Engage patient, family, caregivers, and healthcare providers to assure that a well-coordinated treatment plan is established
Prioritize care needs, set goals and develop a treatment plan (or plan of care) that also addresses gaps and/or barriers to care and uses evidence-based practice as the foundation
Work to facilitate patient compliance and to ensure continuity of care
Monitor and evaluate the patient's response to treatment(s)
Collaborates with internal Medical Directors to attain optimal outcomes and cost efficient services
Regularly assess the effectiveness and quality of services provided to patients by analyzing outcomes (clinical, functional, and financial)
Maintain a focus on timely, quality customer service
Facilitate problem resolution with members, providers, and other agencies or entities as needed
Serves as consumer advocate and maintains consumer's privacy, confidentiality and safety
Registered Nurse (RN) with current active and unrestricted license in the State of residence
Reside within a commutable distance of one of the following locations: Richardson TX, Greensboro NC, Lisle IL, St. Louis MO, West Chester OH, Cincinnati OH, Phoenix AZ, or Eden Prairie MN
Certification in Case Management (CCM)
Home Health or Hospice experience
Medical Surgical experience
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action

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Nurse Case Manager Resume Examples & Samples

Assesses disability status makes recommendations and identifies appropriate resources
Gathers and coordinates medical evidence for evaluation of functionality and makes assessments on restrictions and limitations and addresses length of disability
Consults on case management issues in area of specialty and applies effective case management interventions
Works with medical and other providers to ensure appropriate treatment and return to work
Facilitates job modifications when appropriate and educates involved parties regarding claims process and functionality as it relates to job requirements
Addresses causality and refers to appropriate medical expertise
Documents according to jurisdictional, departmental and accreditation requirements
Strong knowledge of case management, specialty area, medical terminology and conditions, insurance industry as well as company policies and procedures
Ability to exercise professional judgment and assume responsibility for decisions which have an impact on people, costs and quality of service
Excellent verbal, written, and presentation skills with the ability to convey technical issues in a clear, concise and effective manner
Strong interpersonal skills with the ability to effectively interact with internal and external business partners
Detail oriented with strong organizational and analytical skills as well as the ability to prioritize and coordinate multiple tasks
Knowledge of Microsoft Office Suite as well as other business related software
Current unrestricted RN license required
Minimum 3 to 5 years diverse clinical background. Case management or disability management experience required. Workers Compensation experience strongly preferred
Bilingual candidates would be ideal
Certified Case Management (CCM) required or the ability the sit for the exam within 1st year of hire. Additional certifications would be preferred such as; Certified Disability Management Specialist (CDMS), Certified Occupational Health Nurse (COHN), or Certified Rehabilitation Nurse (CRN)
LI-AM1

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Telephonic Nurse Case Manager Rn-pediatric Oncology Resume Examples & Samples

Conduct initial and follow-up assessments within designated timeframes on patients identified as having highest risk complex case management needs (assessment areas include clinical, behavioral, social, environmental and financial)
Assess the patient's current medical and social circumstances to identify any gaps or barriers that would impact compliance with the prescribed treatment plan
Track the patient's health status and progress in achieving clinical and personal goals
Document assessments, interventions, and follow-up on Case Management activities
Participates in special projects, initiatives, and other job duties as assigned
Computer/typing proficiency to enter / retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications
Bachelor’s Degree or higher
Pediatric Oncology experience
Transplant experience

116

Behavioral Health Nurse / Case Manager Resume Examples & Samples

Knowledge of nursing standards, theories, principles, practices, methods, processes, and procedures
Knowledge of federal and state pharmacy and medication clinic regulations and guidelines
Knowledge of psychiatric, psychological, and/or sociological terminology and concepts
Ability to perform mental and physical health assessments and apply treatment approaches/modalities
Ability to assess level of risk for harm to self or others
Ability to maintain records and prepare reports

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Field Nurse Case Manager Resume Examples & Samples

RN or RPN; Registration with the Provincial College of Nurses; case management experience preferred
Minimum three (3) years nursing experience in a clinical setting an asset
Available to travel within an assigned territory, some overnight travel may be required
BCLS may be required depending on therapeutic area of program
Valid Driver’s License, current auto insurance policy and access to reliable transportation, for regional travel
Experience and background in various therapeutic areas is an asset
Normally requires a minimum of five (5) years in public or private third party reimbursement arena or pharmaceutical industry in sales, managed care, or clinical support,
Background in business administration (pharmaceutical) sales and marketing an asset
Knowledge of private and public reimbursement structure, systems, and process
Experience with reimbursement navigation, special authorization, appeals process and conducting field-based reimbursement support and consultation
Strong analytical skills including interpretation of regulation and legislation
Fluency in French and English required

118

Therapy Management Nurse Case Manager Resume Examples & Samples

Graduate from an accredited School of Nursing. Bachelor of Science in Nursing (BSN) preferred
Active Registered Nurse (RN) license in State of Arizona required
Additional active Registered Nurse (RN) license in State of California preferred. Obtaining a California RN license will be required within 6 months of hire
Recent Nurse Manager related experience, and/or at least 3 years of acute medical/surgical nursing experience in an acute care hospital setting, research, or teaching. Experience related to specialty medications preferred. Experience with Oncology and Inflammatory preferred
Experience with telephonic coaching a plus
Proficient with computer software applications such as MS Word and Excel
Knowledge of ICD-9CM and CPT coding preferred
Experience in coding, utilization management review preferred
Strong clinical nursing background. Knowledge of professional nursing principles, clinical processes, and clinical interventions
Working knowledge of clinical practice guidelines and appropriate clinical interventions
Ability to review and incorporate into practice current practice standards from literature
Excellent time management, organization, and negotiation skills
Strong research and analytical skills
Ability to assess complex issues, recommend changes and resolve problems
Knowledge of managed care preferred
Knowledge of compliance standards and measures used to manage patient care

119

Nurse Case Manager Resume Examples & Samples

Provides comprehensive case management and care coordination for a panel of patients with identified needs. “Coaches” (rather than “teaches”) patients to improve their health behavior to attain health-related goals
Completes a comprehensive patient needs assessment for each patient
Develops and communicates (with patient, caregiver and primary care physician/health care team) a comprehensive care plan based on evidence-based best practice for chronic illness
Proactively manages and follows-up (using home visits and telephone calls) according to care plan
Manages and coordinates all transitions of patient’s care. Communicates care plan to all providers in all settings of care (emergency department (ED), hospital, rehabilitation facility, nursing home, home care and specialist). Ensures that relevant providers receive timely clinical data for care treatment decisions in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care, and specialty care)
Directs caregiver support, including ad hoc telephone advice
Facilitates patient and caregiver access to community resources relevant to patient needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services, etc
Incorporates self-care and shared decision making in all aspects of patient care
Complies with health and safety requirements and with regulatory agencies such as DPH, etc
Performs other similar and related duties as required or directed
Active, unrestricted licensure as a Registered Nurse in Massachusetts; current Massachusetts driver’s license
Certified in Geriatric Nursing or Geriatric Case Management preferred. A minimum of five years nursing experience, preferable with older patients
Excellent communication, interpersonal and organizational skills, with a flexible and creative approach to problem solving
Works effectively both independently as well as a member of an interdisciplinary team
Proficient in computer use, the Internet and health information technology
EMR experience preferred
Ability to travel to hospitals, skilled nursing facilities, patient’s homes, and other sites where patients receive care as needed

120

RN Appeals Nurse Case Manager Resume Examples & Samples

Monitor insurance denials by running appropriate reports and contacting insurance companies to resolve claims denied for clinical reasons
Identify coding or clinical documentation issues and work to correct the errors in a timely manner
Identify problem accounts and escalates as appropriate
Update the patient account record to identify actions taken on the account
Work with guarantors to secure payment on account balances outstanding for clinical reasons
Writing Appeal Letters for Authorization and Medical Necessity Denials
Integrates the nursing process (assess, plan, implement and evaluate) and a quality management process (plan, do, check, act) as the framework for decision-making and problem solving
Utilizes professional knowledge to facilitate a physician-specific plan of care, ensure appropriate resource utilization, and coordinate utilization review and approval by payers
Supports and coordinates discharge planning services
Acts as an effective member of an interdisciplinary team in improving quality, service, and financial aspects of overall patient care management
Current Georgia Licensure as a Registered Nurse
Minimum of two (2) years recent acute care experience required, with relevant clinical experience in the assigned area
Case Management Certification preferred
High degree of self motivation and directional initiative
Ability to collaborate effectively with multidisciplinary healthcare teams
Must be able to perform skills and competencies as defined in orientation checklist and annual departmental competency checklist if applicable

121

Nurse Case Manager Resume Examples & Samples

In coordination with the client, develop a tailored plan for healthy pregnancy and transition to motherhood
Inform, educate and guide the client thru the transition and changes in pregnancy and following birth
Liaison between program, worksite and other community agencies
Documentation as established per coaching requirement
Carries out other duties as needed to successfully fulfill the function of the position
Facilitate Support Group activity
Promote a milieu that promotes an effective learning, develop effective nurse/client relationship
Participates appropriately in communication and decision-making activities
Ability to work with several different customer care units and levels of care providers
Maternal Child Health
Early Child Development
Breast Feeding
Maintains current knowledge of plan language and benefit issue

122

RN Nurse Case Manager Denton & Tarrant Counties Bedford Resume Examples & Samples

Create patient-centered care plans yearly and revise quarterly
Discharge planning
Conduct face-to-face “mini” assessments for members in Hospice twice a year
Conduct assessments and coordinate community transitions following the Money Follows the Person program which could include working with NF administrators, coordination of benefits, community visits to determine home modification needs, care team meetings and post discharge follow up
Understand and follows policies and procedures
Produces and submits reports in a timely manner
Identify members with status changes and notify immediate supervisor for appropriate interventions
Knowledge of Medicare and Medicaid healthcare practices and policies
Strong time management, organizational, research, analytical, negotiation, and customer service skills
Strong written and verbal communication skills in order to effectively communicate with members, physicians, providers and plan leadership

123

RN Nurse Case Manager Bedford, Texas Resume Examples & Samples

Works with member to close clinical and pharmacy gaps and to mitigate non-clinical barriers to care
Acts as a liaison and facilitates the coordination of benefits, resources, healthcare providers, and institutions
Previous STAR+PLUS experience
Experience managing members with chronic disease processes and
Experience working with community resource organizations preferred
Experience with care management software applications preferred

124

RN Nurse Case Manager Bedford, Texas Resume Examples & Samples

Conducts a comprehensive in person and/or telephonic member assessment using state mandated assessment tools
Conducts health risk and other member assessments
Uses clinical judgment to identify physical and behavioral health needs and works with the member and caregiver to establish an appropriate plan of care and services that minimize needs based on medical necessity criteria and benefit guidance

125

Nurse Case Manager Resume Examples & Samples

Enroll Patients in our Chronic Care Management program via outbound calls
Assess, Plan, Implement and Evaluate care for patients with chronic diseases
Preparation and documentation of a comprehensive patient care plan and ongoing management of the care plan and care team services in order to meet the patients individual complex health needs
Management of identified gaps in care
Conduct transitions in care and medication reconciliation
Perform telephonic patient triage that establishes a patient disposition
Educate patients in order to enhance their understanding of their illnesses/disease impact and to positively impact their care plan adherence, pharmacy regimen maintenance and health outcomes
Work closely together and coordinate with physicians, patients and their families, caregivers, social workers, health liaisons, community resources and partners in the pharmaceutical and medical industries to ensure a fully integrated care plan that addresses all the patients needs
Actively problem solve with care team and patients to find alternatives or solutions to their medical, behavioral health and social needs
Current and unrestricted RN license Required & 3+ years experience in an Acute, Ambulatory or Managed Care setting
3+ years experience as a Case Manager or Chronic Care Manager
Case Manager Certification (CCM)
Capable of meeting deadlines with no supervision
Capable of training others and answering questions from co-workers when necessary
Strong analytical, interpersonal skills
Strong knowledge of healthcare, government and industry trends

126

Nurse Case Manager Resume Examples & Samples

Conducts telephone assessment of assigned ACO patients/pertinent caregivers to support care coordination activities
Collaborates with other members of the health care team to identify and/or monitor patients at risk for successful transition
Reviews available information sources to support effective transitions of care between care delivery settings and the home environment
Utilizes knowledge of transitional care nursing, chronic disease management, post- acute delivery settings, acute and chronic conditions to perform individualized assessment of patient needs
Conducts assessments to support appropriate referrals (e.g, Centers of Excellence, Home Care) based on patient condition
Incorporates holistic aspects of patient, while applying the nursing process to each patient
Ensures patient safety with each encounter (medication management, review of labs/diagnostics, behavioral health and social concerns) communicates finding with PCP
Assesses patient for the presence of barriers related to successful transitions and the ability to carry out recommended treatment regimen e,g, home safety, adherence, medication safety, caregiver support, willingness to change, safety, cost, psychomotor limitations
Clinical Practice /Care Planning, Prioritization, Coordination
Develops/implements individual plan of care based upon evidence based knowledge
Prioritizes care coordination needs, integrates patient/family education into the development of the plan of care
Communicates plan, findings and outcomes with Primary Care Provider and health-care team at appropriate intervals in consultation with Primary Care provider, recommends and/or facilitates

127

Nurse Case Manager Resume Examples & Samples

Registered Nurse (RN) in State of Arizona (Active and Good Standing)
Minimum of two-three (2-3) years of workers' comp case management experience
Certified Case Manager (CCM) preferred

128

Nurse Case Manager Resume Examples & Samples

Bachelor's Degree or equivalent,
Missouri RN License
3+ years nursing experience required
Case management services, quality monitoring, outcomes analysis, and/or telephonic nursing experience preferred
Clinical experience with sleep disorders and/or REMS programs desired
Ability to: answer telephones, train others, maintain confidentiality of patient health information, compile and analyze data, compose letters, utilize strategic thinking for program/process improvement, act as intermediary with internal and external customers, objectively handle emotional situations, problem solve, coordinate events and meetings and research information
Strong communication skills-written and verbal
Strong customer service skills and well developed interpersonal skills

129

Villagehealth Nurse Case Manager Resume Examples & Samples

Continuing education credits maintained as required by state of practice required
Minimum of five (5) years’ experience in clinical nursing required
Minimum of three (3) years’ experience in renal nursing preferred
Demonstrated knowledge and understanding of data and managing to clinical, financial, and patient satisfaction outcomes
Demonstrated experience and effectiveness in change agent role
Certified Nephrology Nurse (CNN) or Certified Case Manager (CCM) preferred

130

RN Nurse Case Manager Resume Examples & Samples

Minimum 3 years RECENT clinical experience in an acute care case manager*
Minimum 5 years recent clinical experience in an acute care setting required
InterQual experience required*
Experience working with a hybrid medical record preferred

131

Nurse Case Manager Rn-field & Telephonic Resume Examples & Samples

Field visits with members
Field based experience to include home health, hospice, community based care, correctional facilities, etc
Computer proficiency utilizing MS Office, including the ability to type and talk at the same time
Experience working with both Pediatrics and Adults
Reside in the state of Delaware
Ability to be in the field and travel up to 50 miles or 50 minutes from your home
Experience working with special needs or vulnerable population

132

Workers Compensation RN Nurse Case Manager Resume Examples & Samples

Maintain a thorough knowledge and understanding of medical case management practices and HIPPA guidelines in the health care industry
Responsible for ensure appropriate medical services and continuity of care for injured workers
Coordinate medical needs and schedule appointments for appropriate assessment and follow-up until maximum medical improvement (MMI) is achieved
Communicate work status with injured worker, employer and claims adjuster
Communicate network negotiation/recruitment needs to Provider Services, Bill Processing and MCCI departments

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