Case Manager, RN

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 :

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?

Want to see our latest job opportunities? Follow us on LinkedIn

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.