Case Manager-RN (Must reside in NV, OR, WA & licensed in Oregon)

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Must reside in NV, OR, WA and be licensed in Oregon.

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

The position provides Case Management services for TRICARE beneficiaries. The Case Manager is responsible for screening referrals for Case Management and performing a comprehensive assessment. The CM develops and implements an individualized Care Plan and is responsible for monitoring for effectiveness and desired outcomes. Reviews and performs reassessments as needed to ensure identified needs are addressed. CM is responsible for reviewing and processing authorization and referral requests according to policy. Case Managers are responsible for reviewing and being knowledgeable regarding the scope of practice of their state of licensure.

Education & Experience

Required :

Current unrestricted state license as Licensed Clinical Social Worker, Registered Nurse, or Clinical Psychologist

Two years full-time equivalent of direct clinical care to the consumer

Ability to obtain a URAC-recognized certification in case management within four (4) years of hire

Preferred

2 years case management experience

URAC-recognized case manager certification

Key Responsibilities

Applies knowledge of HIPAA privacy and security regulations as well as URAC accreditation standards to ensure compliance in daily practice.

Screens beneficiary needs and circumstances with predetermined program criteria to determine appropriateness for case management. Identifies beneficiaries at high-risk for significant adverse health outcomes and with high-cost, clinical and psychological factors impacting care.

Documents the process by providing the case management enrollment information and acceptance letter to the beneficiary. Provides timely decision of acceptance into the case management program and completes appropriate notifications.

Completes comprehensive case management assessments. Develops individualized case management care plans to assist beneficiaries with obtaining access to quality care in a cost-effective manner. Obtains necessary agreements for obtaining protected health information as needed. Makes the care plan available to the Primary Care Manager or Behavioral Health provider for information and input.

Reassesses and monitors care plans for adjustments on a monthly basis, at a minimum, to address newly-identified needs, services, treatment, and funding options. Documents changes in the care plan maintained in the medical management system.

Evaluates case management outcomes, assessing the individual beneficiary's satisfaction and compliance with the care plan.

Prepares and presents cases involving high-profile or sensitive issues to the Medical Director for review.

Functions as an advocate for the beneficiary by ensuring access to necessary care and maintaining Beneficiary’s safety, locating specialized services outside the network by identifying providers, exploring nature of services offered, and facilitating process.

Supports beneficiaries by providing TRICARE and community resource information and internal care referrals as needed to meet care plan goals.

Understands, administers the TRICARE Specialty Program benefits, including program registration, enrollment, authorizations, and screening for high risk factors indicating appropriateness for catastrophic case management services.

Monitors and provides direction to non-clinical staff.

Regular and reliable attendance is required.

Competencies

Communication / People Skills :

Capacity to effectively influence and persuade individuals in diverse situations, adapt communication styles to varying contexts, actively listen, critically analyze information and foster collaboration.

Computer Literacy :

Proficiency in navigating and utilizing various Microsoft application, including word and Outlook, as well as departmental specific software and internet based tools within a multi-system environment.

Coping / Flexibility :

Capable of navigating through diverse situations and interacting effectively with individuals, while maintaining a sense of purpose and employing mature problem-solving skills, demonstrating adaptability and resilience.

Empathy / Customer Service :

Customer centric approach that ensures patience, respect, attentive listening and empathy toward the perspective of the customer.

Independent Thinking / Self-Initiative :

Resourceful critical thinker who is able to prioritize tasks essential to achieving desires outcomes, demonstration a proactive commitment to task completion and the ability to identify and secure necessary resources.

Multi-Tasking / Time Management :

Proficient in prioritizing and managing task to meet evolving deadlines and requirements amidst a demanding and fast-paced environment characterized by high volume and stress.

Organizational Skills :

Skilled in coordinating people and tasks, adeptly adjusting to changing priorities, mastering systems efficiently within time constraints, and utilizing available resources with attention to detail.

Problem Solving / Analysis :

Proficient in problem-solving through systematic process analysis, guided by sound judgment and grounded in a practical grasp of pertinent issues.

Team-Building / Team Player :

Able to influence the actions and opinions of others in a positive direction and build group engagement.

Technical Skills :

Thorough knowledge of Case Management, Utilization Management, TRICARE policies and procedures, HIPAA Privacy and Security regulations, URAC accreditation standards, Managed Care concepts, Behavioral Health practices and principles, Medicaid and Medicare eligibility requirements and benefits, community resources, alternative funding programs and medical management system. Proficiency with InterQual ISD® criteria (Intensity of Service / Severity of Illness / Discharge Screens); working knowledge of medical coding.

Working Conditions

Working Conditions

Availability to cover any work shift

Works within a standard office environment, with minimal travel required

Extensive computer work with long periods of sitting

Department of Defense security clearance required

Company Overview

Taking Care of Our Nation’s Heroes.

It’s Who We Are. It’s What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®!

Our job is to make sure that America’s heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

Benefits

We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes :

Medical, Dental and Vision Coverage

Paid time off

401(k) Retirement Savings Plan (with matching)

Short-term and long-term disability, basic life, and accidental death and dismemberment insurance

Tuition reimbursement

Paid volunteer time

TriWest job postings typically include a salary range,

which can vary based on the specific role and location , but generally this position ranges from around $83,000 - $93,000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.