RN Case Manager, Military & Family Support Services (Remote)

Essential Duties and Responsibilities:
- Responsible for reviewing favorable, and partially favorable, determinations in accordance with applicable regulations.
- Render medical necessity determinations for Medicare State East cases assigned.
- Resolve all other technical issues within Medicare reconsideration assigned.
- Review cases to determine and summarize facts of each case assigned and assess issues involved in the case.
- May perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary.
- Be the Subject Matter Expert (SME) for project.
- Perform other duties as assigned by management.

- Demonstrated skill in understanding diagnoses to assist clients in optimizing their level of function and self-care.

- Demonstrated knowledge of client education principles and the management of complex medical, psychosocial, and financial problems to enhance adherence to individualized treatment plans and train peers and staff.

- Knowledge and skills in the use of VA/DoW Clinical Practice Guidelines to support an evidence based, standardized process of care for military beneficiaries.

- Knowledge of the healthcare financial environment and the fiscal dimension of population health to ensure optimal stewardship of resources.

- Skill in the use of research tools to critically evaluate existing practices, opportunities, and outcomes.

- Knowledge of pharmaceuticals, including desired effects, side effects, and complications, to gauge their effect on clients and recovery.

- Knowledge of community resources, client entitlement and benefit eligibility, and the ability to access these resources to assist clients and families in optimizing function and self-care.

- Use of pre-established utilization and review criteria, and the ability to recognize and report actual or potential quality and risk management issues to improve practice and ensure compliance.

- Use of information systems and technology to manage individual or population health, continuously improve practice, and effectively communicate practice outcomes to stakeholders.

- Use of computers and software applications to conduct data collection, tracking, trending, and analysis, and to design and present computer-generated outcome analyses for educational programs or project briefings.

Minimum Requirements

- Bachelor's degree with 5-7 years of experience consulting within designated function.
- Advanced degree preferred.
- Develop solutions to highly complex problems which require a high degree of ingenuity and innovation.
- Ensure solutions are consistent with organization objectives.
- Solutions may serve as precedent for future decisions.
- Develop advanced concepts, techniques, and standards requiring a high level of interpersonal and technical skills.
- Develop new applications based on professional principles and theories.
- Viewed as exp...