FEP Case Management - Nurse, Senior

Your Role

Work schedule is Mon-Fri 10am- 7pm

The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members' care including clinical nurses and treating physicians. The Regional Registered Nurse Case Manager will report to the FEP Care Management Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member's needs

Your Knowledge and Experience

• Requires a current CA RN License.
• Bachelor of Science in Nursing or advanced degree preferred
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
• Requires at least 5 years of prior experience in nursing, healthcare or related field
• 3+ years managed care experience preferred.
• Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources preferred
• Behavioral health, oncology, or OB/NICU/pediatrics experience preferred
• Strong electronic clinical documentation skills, independent problem identification and resolution skills
• Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
• Competent understanding of NCQA and federal regulatory requirements
• Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making
• Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care