Case Manager-RN (Must reside in NV, OR, WA & licensed in Oregon) Join to apply for the Case Manager-RN (Must reside in NV, OR, WA & licensed in Oregon) role at TriWest Healthcare Alliance.
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply.
Job Summary
The position provides Case Management services for TRICARE beneficiaries. The Case Manager screens referrals for Case Management and performs comprehensive assessments. The CM develops and implements an individualized Care Plan and monitors for effectiveness and outcomes. Reassessments are conducted as needed to ensure identified needs are addressed. The CM reviews and processes authorization and referral requests according to policy. The CM reviews and is knowledgeable regarding the scope of practice of their state of licensure.
Education & Experience
Required:
Current unrestricted state license as Licensed Clinical Social Worker, Registered Nurse, or Clinical Psychologist
Two years full-time equivalent direct clinical care to the consumer
Ability to obtain a URAC-recognized certification in case management within four (4) years of hire
Preferred:
2 years case management experience
URAC-recognized case manager certification
Key Responsibilities
Apply knowledge of HIPAA privacy and security regulations and URAC accreditation standards to ensure compliance in daily practice.
Screen beneficiary needs and determine eligibility for case management; identify high-risk beneficiaries and those with high-cost, clinical, and psychological factors impacting care.
Document enrollment information and acceptance into the case management program; provide timely decisions and notifications.
Perform comprehensive case management assessments and develop individualized care plans to help beneficiaries access quality care cost-effectively; obtain necessary PHI disclosures as needed; share care plan with relevant providers.
Reassess and monitor care plans monthly (at minimum) to address new needs, services, treatment, and funding options; document changes in the medical management system.
Evaluate case management outcomes, beneficiary satisfaction, and plan adherence.
Present high-profile or sensitive cases to the Medical Director for review.
Advocate for beneficiaries to ensure access to care; locate and coordinate specialized services outside the network as needed.
Provide TRICARE and community resource information and internal referrals to meet care plan goals.
Understand and administer TRICARE Specialty Program benefits, including registration, enrollment, authorizations, and screening for catastrophic case management.
Monitor and direct non-clinical staff; maintain regular and reliable attendance.
Competencies
Communication / People Skills
Computer Literacy
Coping / Flexibility
Empathy / Customer Service
Independent Thinking / Self-Initiative
Multi-Tasking / Time Management
Administrative/Organizational Skills
Problem Solving / Analysis
Team-Building / Team Player
Technical Skills: Case Management, Utilization Management, TRICARE policies, HIPAA, URAC, Managed Care, Behavioral Health, Medicaid/Medicare, community resources, InterQual ISD, basic medical coding
Working Conditions
Availability to cover any work shift
Standard office environment with minimal travel
Extensive computer use and long periods of sitting
Department of Defense security clearance required
Benefits
Medical, Dental and Vision Coverage
Paid time off
401(k) Retirement Savings Plan (with matching)
Short-term and long-term disability, basic life, and AD&D insurance
Tuition reimbursement
Paid volunteer time
Salary information: TriWest job postings typically include a salary range. For this position, the range is generally around $83,000 - $93,000 per year, depending on role and location.
Equal Employment Opportunity: TriWest is an equal opportunity employer. We value diversity and inclusion and encourage candidates from all backgrounds to apply. Applicants are considered based on merit and without discrimination on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other unlawful factor.