Quartz is seeking a licensed RN to join our organization as a Registered Nurse (RN) Case Manager. This role is responsible for conducting clinical review of authorization requests to identify appropriate types and optimal levels of patient care. This role also facilitates referrals between health plan members, participants, primary care physicians and other health care providers.
- Utilize clinical judgment and knowledge of established standards to make coverage determinations based in individual member circumstances
- Conduct prospective, concurrent, and retrospective medical reviews for coverage determinations of managed care members
- Review medical records, conduct telephone assessments, and patient/nurse/physician interviews, and provide referrals to appropriate agencies, as needed
- Investigate and facilitate all alternatives to services requested when specific requests cannot be authorized
- Analyze data for case selection process utilizing resources such as claims, hospital discharge, pharmacy, and utilization management data as well as data supplied by other resources such as purchasers, member or caregiver, and practitioners
- Care Management - establish objectives, goals and actions designed to meet patient’s needs and monitor the care plan to ensure effectiveness and appropriateness of services; practice conflict resolution strategies, as needed
- Obtain accurate and detailed clinical information from appropriate sources to facilitate clinical review of cases; maintain information for reporting purposes
- Maintain confidentiality and adhere to the professional standards and ethics of the healthcare field and managed care industry
- Serve as the medical liaison between contracting staff and case managers, interpreting contractual language to determine payment issues and collaborating with all parties to resolve contract issues based on medical appropriateness, as needed.
- Bachelor’s Degree in nursing or related field
- State of Wisconsin RN license
- 2-3 years of RN case management experience in a clinical and/or inpatient setting
- Valid Driver’s license with the ability to travel, as necessary, within the designated service area
- State of Illinois RN license is preferred, or ability to obtain upon hire
- Certified Case Manager, or related certification, preferred
- Working knowledge of managed care as it relates to contracting in health insurance, per diems, DRG’s CPT and ICD-9 coding
- Exceptional customer service skills: Understand needs of culturally diverse populations including ability to evaluate for literacy and literacy needs
- Strong written and verbal communication skills interacting with individuals internally and externally
- Strong independent, critical thinking skills to understand individual and operational problems and identifying appropriate solution(s)
Applicants will work full-time from our office in Madison, WI for at least the first year of training and onboarding. Opportunities to work from home will also be available to successful individuals who can demonstrate the ability to independently perform the duties of the job after the initial training period of one year. Quartz offers an excellent benefit and compensation package, opportunity for professional growth and a professional culture built upon the foundation of Respect, Responsibility & Relationships.
Quartz values and embraces diversity and is proud to be an Equal Employment Opportunity, Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity or expression, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.