Case Management RN

Case Management RN (Registered Nurse) coordinates care and services of select member populations with complex health care needs across continuum of care. The primary focus of the role is the development and continuous monitoring of a member-centric plan of care that promotes effective utilization of health care services while maximizing quality and cost-efficiency of these services for members. Case Management RN routinely educates members and family members on plans of care while serving as a liaison between the members, their families and health care providers. We are open to remote work in the following approved states: Have developed and implemented individualized care plans, short term and long-term goals for case managed members. Enjoy reviewing and providing prior authorization decisions for selective high-cost services including but not limited to transplant, dialysis, CAR-T/gene therapy. Would like serving as an advocate for the member’s needs and preferences and can identify and address barriers to care. Would like to coordinate medical services and resources, facilitate transitions of care between settings, and assist with site of care redirections as needed. Can help members manage their conditions and address unique issues during their care transitions. Enjoy educating members and caregivers on appropriate and available community resources, how to prepare for physician visits, and how to overcome barriers and achieve medication compliance. Can assess motivational or psychosocial issues for case managed members and facilitate case management members to achieve wellness and autonomy. Have the ability to identify legal or liability issues and refer potential ethical or risk management issues to the appropriate department for review and resolution. Can document all care management activities and analyze / report care management activities that could include, identification of high risk, high cost and high utilization cases. Have maintained accurate, up-to-date case notes, care plans, and other documentation in compliance with health plan guidelines, state, and federal regulations. Can work cross functionally to support other departmental efforts to ensure overall efficiency, quality, productivity and compliance with all departmental and regulatory standards. Registered Nurse (RN) with current licensure in the state of Wisconsin 4 or more years of experience as a Registered Nurse in varied clinical settings (i.e., hospital, clinic, home care, skilled nursing facility, etc.). 2 or more years of case management experience. Demonstrated experience managing and coordinating care effectively for case managed members. Strong knowledge of clinical care management processes, care coordination, and case management principles. Familiarity with health operations, payer/provider relationships, and insurance benefits. Proficiency in Microsoft Office and healthcare software and systems. Bachelor’s degree in nursing (BSN). Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement) plans preferred. Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software. Remote Work Requirements High speed cable or fiber internet Please review Remote Worker FAQs for additional information Remote work options available Performance bonus and/or merit increase opportunities 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary ( 100% vested immediately ) Health insurance, dental insurance, and telehealth services start WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready. We are proud of the recognition we have received from local and national organization regarding our culture and workplace: LinkedIn Facebook WPS Health Blog