Job: Nurse Case Manager

Department: Utilization Review/Management
Location: Community First Health Plans

JOB DESCRIPTION: Nurse Case Manager CFHP, Utilization Management
POSITION CODE:4117
DEVELOPED:10/08

POSITION SUMMARY/RESPONSIBILITIES:
Identifies Community First Health Plan members with specific health care needs and provides case management interventions. Analyzes, approves health care services and monitors outpatient care planning for Community First Health Plans members based on established criteria, plan policies and procedures. Formulates and communicates case management plans that efficiently utilize health care services to move the member along the continuum of care towards optimum outcomes in the safest, most cost effective manner.

EDUCATION/EXPERIENCE
Graduation from an accredited school of professional nursing is required, BSN preferred. Masters degree is preferred. Minimum three years acute care experience or managed care experience is required. Minimum one-year of concurrent review experience is required. Candidate must have utilization management and/or quality assurance experience. Basic knowledge of Medicaid, community resources and alternate funding programs is desired. Knowledge of InterQual screening criteria as well as DRG, ICD-9 and CPT coding is preferred.

LICENSURE/CERTIFICATION
Current Registered Nurse license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) designation is preferred.