The Case Manager manages an individual caseload using the case management process in order to meet the needs of the MedWatch, LLC customers and consumers. This includes, but is not limited to, authorization of services, review of treatment plans for medical necessity, standards of care, and ongoing communication with all members of the health care team. This is a remote/work‑from‑home position.
License Requirements
Registered Nurse (current active and unrestricted, in state of current practice and residence, within the United States or its territories.)
Education
R.N., a bachelor’s degree in a health‑related field preferred.
Experience
7 years of varied clinical experience preferred.
Responsibilities
The Registered Nurse Case Manager will practice within the scope of his/her licensure.
Review all medical data to establish, update and maintain accountability for a case management plan, incorporating contact with providers, payers, the patient and the patient’s primary caregiver.
Assess problems and determine goals and actions designed to meet the needs of the patient, documenting into the case notes. Determine if these goals are long‑term or short‑term and how the patient can be expected to meet those goals. Include the action/intervention the case manager will take to work toward achieving those goals.
Make contact with the payer office to understand any benefit constraints that will impact the plan of action.
Contact medical care providers and equipment vendors to verify medical necessity of ordered care or equipment.
Make care arrangements for quality patient care per the patient’s needs, the physician’s orders and the available benefits.
Work in conjunction with the Case Management Assistant to manage case files, excluding Assessment and/or Care Plan activities, and provide input in the Annual Performance Evaluation of the assigned CM Assistant. Maintain responsibility for the Case Management file.
Be aware of alternative treatment possibilities that may allow the patient to reach wellness goals. If no benefits cover recommended alternatives, provide a cost‑benefit analysis to the payer to demonstrate that extra‑contractual services are cost‑effective.
Become familiar with community resources and funding sources so the patient can receive quality health care and conserve benefit dollars.
Maintain the case in the computer system, documenting all actions. Prepare timely reports to the payer detailing case actions and the continuing case management plan.
Maintain billing as appropriate in the computer system.
Continue contact with providers and the patient across the continuum of care to ensure needs are met. For chronic conditions, keep the file open for periodic contacts to verify clinical status and additional medical needs.
Negotiate with providers to maximize medical benefits available to the patient. Make network referrals as appropriate.
Act on any awareness of non‑medical issues involving the patient’s safety or welfare, directing the patient or family to appropriate resources or authorities, and consult with the CM supervisor regularly. Keep the supervisor informed of complaints or issues that the case manager cannot handle.
Adhere to all company policies as stated in the employee handbook.
All case managers will possess a URAC‑recognized certification in Case Management within 3 years of hire. Participate in the Quality Management Program by adhering to company policies and procedures and identifying opportunities for improvement.
This position is eligible for a bonus program.
The salary range for this position is from $72,000 to $81,000 annually.
Work Environment / Physical Demands: This position is in a typical home office environment which requires prolonged sitting in front of a computer. It requires hand‑eye coordination and manual dexterity sufficient to operate standard office equipment, including a computer and phone.
We are an Equal Opportunity Employer, including disability/veterans.