Employee type: 

Full-Time

Job type: 

Insurance

Industry: 

Healthcare - Health Services

Manage others: 

No

Education: 

4 Year Degree

Experience: 

3

Travel: 

Extensive

Care Management Review Nurse (Spanish-Bilingual, RN)

Requires CA Registered Nurse license. Spanish-Bilingual skills and availability to travel regularly. 

 As a Care Management Review Nurse you will be responsible for the management and operation of the Care Management programs that we offer our employer groups. You will ensure program compliance, promote quality care and effective cost savings for our patients and clients.

What you get to do:

  • Coordinate the care management review process (electronically & telephonically) of other health care companies as necessary (i.e. Anthem) and provide assistance with problem resolution; determine physician advisor involvement on a case-by-case basis.
  • Provide assistance to the claims examiners or customer service staff as needed when updating the system notes regarding managed cases.
  • Interact (electronically & telephonically) with employees of other carriers such as Blue Cross and other networks to resolve pricing and contract issues.
  • Monitor large dollar case management clients to ensure effective cost savings while assuring the client receives quality health care.
  • Perform pre-admission (telephonically), concurrent and retrospective review for Anthem and non-Anthem plans.
  • Interact (electronically, telephonically, and inperson) with clients as necessary to assist with care management questions/issues regarding their employees.
  • Obtain case management notes for re-insurance carriers, and provide prognosis reports for high dollar cases.
  • Provide prognosis reports for the Underwriting Department, as needed.
  • Develop and present health educational sessions around health, nutrition and other care management topics on a monthly basis.

Requirements: 

  • BA/BS degree and three to five year experience working care management programs for companies offering employee health benefits preferred.
  • Current RN licensure to practice in the State of California.
  • Currently or willing to become licensed as Certified Case Manager (CCM).
  • Good understanding of health benefits claims processing.
  • Expert in current claims coding practices.
  • Excellent oral and written communication skills in English and Spanish.
  • Ability to travel (40%) primarily around Fresno, however can include other parts of CA and on occasion AZ.
  • Must have valid driver license and good driving record.

Send resume to Lola da Silva, ldasilva@WGA.COM 

 

 

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