Ensures member access to services appropriate to their health needs. Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Ensure compliance with healthcare regulations and monitor adherence to contractual obligations. Ability to handle unexpected changes in assignments and members needs and manage a flexible schedule accommodating field visits and emergency situations. Valid driver’s license, reliable transportation, and ability to travel within the service area as needed. Conduct facility, hospital, or home visits to monitor and evaluate care as applicable and/or required. Maintaining meticulous records of interactions, decisions, and care plans for compliance and audit purposes. Proficiency in using mobile devices, multiples systems, and technology to access member records, document visits and reports, and communicate with the central office. Competence in addressing quickly arising issues effectively, often requiring creative and immediate solutions. Minimum Requirements:Requires BA/ BS in a health related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. Preferred Skills, Capabilities, and Experiences:Certification as a Case Manager is preferred. Prior hospital experience is preferred. Job Level:Non-Management Exempt. Workshift:1st Shift (United States of America)