Care Management Referral Analyst, RN

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🔥 1 hour ago

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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GuideWell Source

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

GuideWell Source is a company within the GuideWell Family that focuses on accelerating innovative health solutions to market, transforming and reshaping the health industry. It specializes in healthcare delivery, providing new models and superior outcomes for patients. The company emphasizes consumerism in healthcare, engaging clients in meaningful ways. GuideWell Source offers healthcare insurance, protecting employers and consumers with coverage plans and services. The company also provides administrative and claims processing services for state and federal Medicare and Medicaid programs, establishing itself as a trusted business partner in the healthcare sector with a focus on operational excellence.

📋 Description

• Monitor and review referrals received from Utilization Management authorization triggers, high-dollar claimant reports, emergency room utilization reports and internal referrals from other care management departments and any departments that handle case management workflow. Assesses and assigns cases for medical case management based on acuity, staffing levels and clinical information available. • Review clinical information supplied in UM authorizations, claims data/activity as part of the assessment process. Ensures additional documentation is uploaded to the case should documents and/or information need to be attached to a cases that is being referred. • If a referral is not appropriate to fully open for Case Management, but the referred member could benefit from an alternate outreach campaign or initiative, the Referral Analyst will assist with identification of alternate care outreach plans for that member. These alternate plans will be based on plan/group resources (e.g. MES outreach around a specific concern).

🎯 Requirements

• 5+ years related work experience with a professional background in clinical nursing and patient assessment. • Related BSN degree or additional related equivalent work experience • Graduate of an accredited school of nursing • RN - Registered Nurse - State Licensure • ICU experience with higher-acuity patients in a clinical setting. 10+ years of extensive experience in various medical-surgical units will be considered, in substitute. • Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices. • Ability to collaborate with cross-operational areas within the organization.

🏖️ Benefits

• Medical, dental, vision, life and global travel health insurance • Income protection benefits: life insurance, Short- and long-term disability programs • Leave programs to support personal circumstances • Retirement Savings Plan includes employer contribution and employer match • Paid time off, volunteer time off, and 11 holidays • Additional voluntary benefits available and a comprehensive wellness program