Offer summary

Qualifications:

Nursing degree from an accredited institution., Active, unrestricted Registered Nurse license with required CEUs., At least 1 year of experience in Utilization Management or Case Management., Willingness to obtain and maintain additional licenses and certifications, such as Certified Case Manager..

Key responsibilities:

Perform case management activities using clinical guidelines and policies.

Conduct clinical assessments and coordinate medical services for members.

Review medical necessity, utilization, and benefits as part of pre-determination processes.

Document all case management steps accurately using assigned software.

Job description

Imagine360 is currently seeking a Case Manager RN to join the team! The RN is responsible to providing case management for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical and professional experience.

Position Location: 100% Remote

Responsibilities include but are not limited to:

Identify, collect, process and manage data to perform the Case Management process by utilization Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures
Completes clinical assessments per P&P to identify and deliver indicated medical service coordination
Completes medical necessity, utilization management reviews, and review of benefits as part of the pre-determination process
Identify and refer cases for Physician Advisor reviews
Utilize clinical knowledge, expertise and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment
Assess the need for and collaborate with community resources for members in case management
Perform negotiations with providers
Uses assigned software accurately to document to complete and document all steps of review of medical necessity and case management process, including time slips
Facilitate the Patient Satisfaction Surveys
Assess for cost savings and document the cost saving in assigned software platform
Appropriately refer complex cases to Manager, Case Management
Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite
Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and Medical Management Policy and Procedure
Participate in the Quality Management Program via collecting and adhering to performance metrics per Case Management Policy

Required Experience / Education:

Nursing degree from an accredited college, university, or nursing school
Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization
1+ year in Utilization Management, Case Management or transferable skills
Pediatrics and or NICU experience is a plus.
Must be a Certified Case Manager or eligible to sit for the Certified Case Management Exam within 3 years of starting employment with i360.
Must have intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software

Licenses and Certifications:

Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization

What can Imagine360 offer you?

Multiple Health plan options
Company paid employee premiums for disability and life insurance
Parental Leave Policy
20 days PTO to start / 10 Paid Holidays
Tuition reimbursement
401k Company contribution
Company paid Short & Long term Disability plus Life Insurance
Professional development initiatives / continuous learning opportunities
Opportunities to participate in and support the company's diversity and inclusion initiatives

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**

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