Care Manager

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• Identify and connect high-risk members to appropriate resources and programs to achieve optimal quality and financial outcomes • Manage and triage self-referrals to care management programs • Identify high-risk members through HRA, reporting, and admissions data • Audit patient charts and member records for delegated case management programs using NCQA standards • Connect members with in-network providers, medical benefits, community resources, and programs • Perform utilization management reviews according to established criteria, clinical guidelines, and policies • Identify barriers affecting members’ quality of life • Evaluate Health Risk Assessment and member outcomes data to support program development and performance improvement • Investigate potential quality-of-care issues affecting member health or safety • Review medical records and documentation to ensure quality care • Participate in care management, case management, and quality committees • Review and update activities, resources, policies, and procedures to address member needs and align with delegated processes • Assist with quarterly reporting and submission of required documents and policies to meet accreditation standards

🎯 Requirements

• Current Registered Nurse license issued by the state in which services will be provided, or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC) • Three years of healthcare clinical experience • Working knowledge of InterQual and/or Milliman Care Guidelines • Knowledge of federal and state laws, NCQA standards, and industry regulations related to disease management, utilization management, care management, and discharge planning • Excellent written and oral communication • Problem-solving capabilities to improve efficiencies and customer satisfaction • Attention to detail • Proficiency with Microsoft Office • Bachelor's Degree in Nursing or Associate of Science in Nursing Degree (ASN) is preferred • Currently enrolled in a BSN program, with BSN completion within three years of hire, is preferred • Experience managing Medicare and/or Medicaid populations is preferred • Two years of Care Management experience is preferred

🏖️ Benefits

• Remote work location • Full-time schedule with 40 scheduled weekly hours • Exempt status