90 Degree Benefits is seeking a full-time RN Case Manager to join our team. The ideal candidate will have responsibilities in the following areas: utilization review and processing of authorization requests, disease management, wellness mentoring, risk assessment, and Stop Loss (SL) reporting, all performed according to policies and procedures of 90 Degree Benefits.
This position will evaluate and manage catastrophic episodes of illness for 90 Degree Benefits’ client members and ensure that the insured is receiving the best medical care in the most cost-effective manner.
Essential Duties and Responsibilities:
Acquire member information and maintain records and proficiency in the use of the clinical and claims software programs to include Deerwalk (Plan Analytics, Care Manager and Health Portal) and claims systems.
Review policyholder data to identify claimants with catastrophic care needs, and assess medical and claims information available to calculate potential risk and large loss claims, using the Utilization Review process, predictive modeling, Deerwalk Plan Analytics Cohorts, claims referral, pending claim reports, customer service referral, client referral, and other methods as indicated.
Assure high risk and potential large loss individuals are flagged in the Care Manager system for SL reporting, evaluated for SL notification/reporting and assessment of ongoing claim potential, and referred to management for review.
Provide written claimant assessments within established deadlines for Account Managers to use when meeting with Brokers to establish rates for new and renewal business.
Generate renewal reports, including the SL/Case Management Summary, Trigger Diagnosis, Precert, and Discharge reports.
Provide reports for inclusion in group’s SL renewal and/or management report packet.
Participate in meetings to provide the clinical aspect of SL renewals.
Attend the occasional health fair and/or client meeting to educate and mentor.
Maintain industry awareness of new diagnoses, treatments, costs, and industry trends.
Respond to verbal or written requests and provide clinical opinion from knowledge, experience, and research.
Assist with assessing and recommending effective claim cost containment and healthcare trends for clients for potential solution implementation or wellness mentoring.
Perform other activities and clinical functions, as requested.
Maintain licensure, certification, and continuing education as indicated for case management, utilization review, wellness, and chronic condition management programs and the professional staff.
Bachelor’s degree (or higher) in Health Care Administration, Nursing or related field from a four-year college or university or equivalent combination of experience and education.
Five or more years of management experience in utilization review/case management in the self-insured environment.
Experience with TPA, SL reinsurance contract administration, risk management and quality assessment preferred.
Case Management certification (CCM) desired. Utilization Management, Disease Management and/or Wellness Certification considered a plus.
Understanding of legal and ethical issues pertaining to confidentiality and liability associated with utilization management, case management, wellness plans, and benefit administration.
Data analytics and report preparation experience and the ability to explain findings to clients.
Excellent communication skills; ability to write procedures, reports, and correspondence and speak effectively in group presentations and training seminars.
Strong organizational skills; ability to work with multiple projects simultaneously and complete assignment within prescribed time frame.
Ability to deal with problems and apply understanding to complex administrative issues.
Additional Salary Information: Salary is determined based on skillset, education, and experience.
About Corporate Benefits Service, Inc., a 90 Degree Benefits' company
90 Degree Benefits is a health benefits company with a mission: to help employers Make the Right Turn™ for their business through strategically crafted benefit offerings. With every business being unique, no path to success looks the same. 90 Degree Benefits designs health plans and administers benefits that meet each employer’s unique health and operational needs, both now and for the road ahead.
We believe the right health plan does more than just provide benefits. It provides peace of mind for both employees and employers and contributes to the overall success of the organization. The 90 Degree Benefits vision is to help each employer Make the Right Turn™ for their business.