Full-Time

Primary Nurse Case Admin I

Posted on 12/3/2024

HCSC

HCSC

Health insurance provider in multiple states

Financial Services
Healthcare

Compensation Overview

$58.8k - $130.1kAnnually

Mid

Houston, TX, USA + 3 more

More locations: Austin, TX, USA | San Antonio, TX, USA | Richardson, TX, USA

Must reside within 250 miles of the office or anywhere within Texas.

Category
Nursing & Allied Health Professionals
Medical, Clinical & Veterinary
Requirements
  • Registered Nurse (RN) with current, valid, unrestricted license in state of operations
  • 2 years clinical practice experience of direct clinical care to the customer
  • 1 year experience in Condition Management or Case Management in a health insurance, managed care, physician office or hospital setting.
  • PC proficiency to include Word, Excel, Lotus Notes and database experience
  • Clear and concise verbal and written communication skills
  • Knowledge of UM/CM/DM activities and standardized criteria set
  • Familiarity of ancillary services including HHC, SNF, Hospice, etc
  • Verbal and written communication skills; analytical skills; sound clinical judgment
  • Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management. Multi-state license fees will be provided by HCSC. Incumbents with other clinical licenses are not required to obtain multi-state licenses.
  • Experience in managing complex or catastrophic health cases
  • Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
  • Working toward or completion of CCM/CCP/CDE certification or Advanced degree
  • Knowledge of Milliman Guidelines or similar clinical guidelines
  • Knowledge of medical management policies and procedures
Responsibilities
  • performing all functions of Utilization Management (UM), Case Management (CM) and Disease Management (DM)
  • single source of contact for members, health care personnel and all other entities involved in managing care
  • perform concurrent review, discharge planning and care coordination
  • identify alternate treatment programs
  • consult with physicians, providers, members, and other resources to evaluate options and services required to meet an individual’s health needs
  • promote quality and cost effective outcomes
  • serve as liaison to physicians and members
  • episodic case management
  • determine member assignment of treatment
  • pre-admission/post-discharge counseling for an acute condition
  • establish relationship with the member through the immediate post discharge follow-up period or until all short term care needs are met
  • provide education/local resource information and encourage member (self) education
  • assess members for wellness education and disease management
  • introduce members to our website tools
  • educate members regarding wellness and specific conditions
  • facilitate the coordination of care for identified members

HCSC provides health insurance services across five states: Illinois, Montana, New Mexico, Oklahoma, and Texas. The company offers a variety of health insurance plans designed for individuals, families, and businesses, ensuring that different healthcare needs are met. HCSC's plans work by collecting premiums from members, which fund the healthcare services they provide. In addition to insurance, HCSC invests in health and wellness programs aimed at lowering healthcare costs and enhancing the health outcomes of its members. What sets HCSC apart from other health insurance providers is its long-standing experience in the industry and its commitment to compassion and innovation in healthcare. The company's goal is to empower people to lead healthier lives while maintaining a focus on quality care.

Company Stage

N/A

Total Funding

$472.7M

Headquarters

Chicago, Illinois

Founded

N/A

Simplify Jobs

Simplify's Take

What believers are saying

  • The new Houston office will create numerous job opportunities, fostering local economic growth and community development.
  • The acquisition of Cigna's Medicare businesses will expand HCSC's product offerings and geographic reach, benefiting current and future members.
  • Recognition as one of the 'Best Places to Work in IT' and having a CEO listed among the 'Most Influential People in Healthcare' highlight HCSC's strong leadership and positive work environment.

What critics are saying

  • The $231,900 fine from the Illinois Department of Insurance for an inaccurate provider directory could damage HCSC's reputation and trust with members.
  • The integration of Cigna's Medicare businesses may pose operational challenges and potential disruptions.

What makes HCSC unique

  • HCSC's strategic expansion into local communities, such as the new Houston office, emphasizes its commitment to economic growth and local workforce development, setting it apart from competitors.
  • The acquisition of Cigna's Medicare businesses significantly enhances HCSC's capabilities and reach in the growing Medicare market, providing a competitive edge.
  • HCSC's collaboration with Feeding America to address root causes of hunger showcases its holistic approach to community health, beyond traditional healthcare services.

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