Peak Care Manager
RemoteUnited States
United StatesRemoteFull TimeAssociates DegreeSmall
Full TimeAssociates DegreeSmall
Job Summary
Manage and triage member self-referrals to care management programs while performing utilization management reviews according to established clinical guidelines. Identify high-risk members through Health Risk Assessment data and connect them with in-network providers and community resources to achieve optimal quality and financial outcomes. Audit patient charts against NCQA standards, investigate potential quality of care issues, and assist in quarterly reporting to meet accreditation requirements. Review member outcomes data to drive performance improvement initiatives and update policies to align with delegated processes.
Required Qualifications
- 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 (3) years of healthcare clinical experience
Desired Qualifications
- Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN)
- Currently enrolled in a BSN program and BSN completion within three (3) years of hire
- Management of Medicare and/or Medicaid populations
- Two (2) years Care Management experience
- Working Knowledge of InterQual and/or Milliman Care Guidelines
- Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, care management and discharge planning
- Excellent written and oral communication
- Problem solving capabilities to drive improved efficiencies and customer satisfaction
- Attention to detail
- Proficiency with Microsoft Office
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