Remote Utilization Review Rn Jobs in Iowa (NOW HIRING)

Why Wellmark: We are a mutual insurance company owned by our policy holders across Iowa and South Dakota, and we've built our reputation on over 80 years' worth of trust. We are not motivated by profits. We are motivated by the well-being of our friends, family, and neighbors-our members. If you're passionate about joining an organization working hard to put its members first, to provide best-in-class service, and one that is committed to sustainability and innovation, consider applying today! 

Learn more about our unique benefit offerings here. 

Use Your Strengths as a Case Management Nurse I at Wellmark! 

About the role: As a Case Management Nurse I, you will serve as a key advisor who actively engages with members through a variety of channels to foster a caring and trusting level of connection in order to support their chronic and/or complex health care needs and concerns. You will create and manage unique, individualized care plans that ensure the best possible health care goals and complex health needs are reasonably met. You will partner with members, members' families, health care providers and community resources to coordinate and facilitate care and services.  

About you: You are a dedicated, caring health care professional motivated and inspired by the opportunity to provide ongoing personalized support and education to our members. You thrive in a fast-paced work environment where your time management, prioritization, and multi-tasking skills are critical to success. You see yourself as being resourceful, collaborative and adaptable with a keen ability to influence. Technology savviness, such as experience in utilizing and troubleshooting Microsoft Office products (Outlook, Excel, Teams, etc), is a must.  

Candidates located in Iowa or South Dakota preferred. Top candidates will have prior health plan experience along with a diverse clinical background, including behavioral health experience.

In this position, you will be required to obtain a Certified Case Manager (CCM) certification within 24 months from date of hire and maintain throughout time served in position. This role is remote eligible and will require candidates to provide high-speed internet at their work location. 

Preferred Qualifications - Great to have:

• Certified Case Manager (CCM).
• Care navigation/care coordination experience strongly preferred.
• Behavioral health experience.

Required Qualifications - Must have:

• Completion of an accredited nursing program.
• Active and unrestricted RN License in Iowa or South Dakota. Individual must be licensed in the state in which they reside.
• Certified Case Manager (CCM); must obtain within 24 months of hire.
• 4+ years of diverse clinical experience (e.g., acute care, outpatient, home health, etc.) that reflects 4+ years of direct clinical care to the consumer. Experience in utilization management or health insurance setting beneficial.
• Strong verbal communication skills; influences action and facilitates crucial conversations regarding care with members, physicians, and care facilities.
• Maintains courtesy and professionalism when engaging with members, internal and external stakeholders.
• Strong written communication skills, including accurate documentation of events within the case management platform; ensures quality and consistency by following guidelines and processes.
• Commitment to service excellence and member advocacy; uses critical thinking and problem-solving skills to anticipate member and provider needs.
• Resourceful self-starter who demonstrates strong understanding of resources, processes, and guidelines. Able to make independent decisions or recommendations under ambiguity.
• Ability to organize and manage multiple priorities in a dynamic work environment where quality and/or production goals are measured. Commitment to timeliness, follow up, accuracy and attention to detail. Flexible and adapts to change.
• Strong technical acumen; learns new systems quickly - e.g., Microsoft Office, clinical documentation platforms, etc.
• Knowledge of standards and regulations - e.g., URAC, NCQA, HIPAA, PHI confidentiality.

What you will do as a Case Management Nurse I:

*Must be flexible and have the ability work weekend and/or holiday hours when needed on a rotational basis.

a.  Utilize critical thinking to recognize signs and symptoms of potential high-risk and complex conditions that warrant different or greater levels of support and proactively anticipate member needs in the navigation of the health care system and the benefits and resources available.

b. Discuss the care needs with the member through supportive, focused intervention methods and effective planning techniques.
c. Proactively identify barriers and gaps to care while designing, creating, and managing unique, individualized care plans that ensure members/providers have good communication channels, that members receive appropriate care, that potential duplication of services is avoided, and education is provided to help enable them to achieve the best possible health care goals.
d. Partner with members, members' families, health care providers and community resources to coordinate and facilitate the care and services needed.
e. Actively engage members as participants in their unique care management plan and educate on their personal accountabilities and expected outcomes. Advise on included benefits and services that are appropriate for their current medical status, and how those benefits and services can positively impact not only their medical status, but also the total cost of care.
f. Stay curious and engaged by actively continuing to partner with other members of the Wellmark Team and research appropriate resources and/or programs as science and technology evolves, that may help to improve the health of assigned members going forward. Continue collaborative efforts with other clinical and nonclinical stakeholders, both internal and external to Wellmark, to provide optimal service and meet the needs of the member and coordinate care. Facilitate additional referrals to providers, community resources/programs, and specific Wellmark programs, as necessary.
g. Using relevant technology tools, document care management activities accurately, consistently, and timely by following the standard work guidelines and policies to support internal and external processes. Comply with regulatory standards, accreditation standards and internal guidelines. Remain current and consistent with the specific standards pertinent to the Care Management team.
h. Other duties as assigned.

Remote Eligible: You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other 'moments that matter' as well.  

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.

Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at [email protected]

Please inform us if you meet the definition of a "Covered DoD official".

At this time, Wellmark is not considering applicants for this position that require any type of immigration sponsorship (additional work authorization or permanent work authorization) now or in the future to work in the United States. This includes, but IS NOT LIMITED TO: F1-OPT, F1-CPT, H-1B, TN, L-1, J-1, etc. For additional information around work authorization needs please refer to the following resources:Nonimmigrant Workers and Green Card for Employment-Based Immigrants 

Wellmark supports and expects the responsible use of AI for our workforce! We welcome the responsible use of these tools by job seekers as well and are interested in learning from you; you will have an opportunity in the application process to share which tools you used and how you applied them.