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RN Intensive Case Manager
Ref No.: 18-00076
Location: Denver, Colorado
Position Type:Contract
Start Date: 01/03/2018
JOB SUMMARY: Under minimal supervision, provides medical and/or behavioral health utilization management for members of Denver Health Medical Plan in accordance with the schedule of benefits and network criteria defined by the Plan's various lines of business and Center of Medicare & Medicaid Services ( "CMS”) regulatory requirements. Completes clinical review to determine whether a request can be approved using nationally recognized criteria such as InterQual or MCG, or requires additional review by the Plan's Medical Director.


MINIMUM QUALIFICATIONS:

Education: Bachelor's degree in Nursing. A combination of education and experience may be substituted for the B.S.N. requirement.

Experience: Typically, three years of medical utilization management experience working with a health insurance plan, hospital, skilled nursing facility, or surgical center. Managed Care experience is highly preferred.

Knowledge, Skills & Abilities: Knowledge of major concepts, principles and theories related to nursing process. Experience evaluating medical utilization requests using criteria such as InterQual or MCG is required. Working knowledge of adult and/or pediatric health issues. Knowledge of the special health care needs of the Medicaid/Medicare population. Basic knowledge of managed care and case management principles. Skilled in critical assessment, analysis, and problem solving , including being able to find workable solutions to complex problems. Excellent time management and critical thinking skills. Strong written and verbal communication skills, including effective telephonic communication. Ability to work well with all types of providers/customers. Ability to work autonomously and in a team environment. Ability to establish and maintain rapport and therapeutic relationships with individuals, families, groups, and communities. Experienced in using care management software. Proficient in using Microsoft Outlook, Word, PowerPoint, and Excel. Bilingual English/Spanish is desirable.


Certificate/License/Registration: RN License required to practice in the State of Colorado (or compact state). Certification in Case Management ( "CCM”) or related certification preferred. All Certifications and Licenses required for this job must be kept current as a condition of continued employment.

ESSENTIAL DUTIES & RESPONSIBILITIES: List each job duty and responsibility that is essential to performing the job successfully, efficiently and safely