Case Manager-RN (Must reside in NV, OR, WA & licensed in Oregon)

Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®! Our job is to make sure that America’s heroes get connected to health care in the community. At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

Profile: Must reside in NV, OR, WA and be licensed in Oregon. Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary: The position provides Case Management services for TRICARE beneficiaries. The Case Manager is responsible for screening referrals for Case Management and performing a comprehensive assessment. The CM develops and implements an individualized Care Plan and is responsible for monitoring for effectiveness and desired outcomes. Reviews and performs reassessments as needed to ensure identified needs are addressed. CM is responsible for reviewing and processing authorization and referral requests according to policy. Case Managers are responsible for reviewing and being knowledgeable regarding the scope of practice of their state of licensure.

Applies knowledge of HIPAA privacy and security regulations as well as URAC accreditation standards to ensure compliance in daily practice. Screens beneficiary needs and circumstances with predetermined program criteria to determine appropriateness for case management. Identifies beneficiaries at high-risk for significant adverse health outcomes and with high-cost, clinical and psychological factors impacting care. Documents the process by providing the case management enrollment information and acceptance letter to the beneficiary. Provides timely decision of acceptance into the case management program and completes appropriate notifications. Completes comprehensive case management assessments. Develops individualized case management care plans to assist beneficiaries with obtaining access to quality care in a cost-effective manner. Obtains necessary agreements for obtaining protected health information as needed. Makes the care plan available to the Primary Care Manager or Behavioral Health provider for information and input. Reassesses and monitors care plans for adjustments on a monthly basis, at a minimum, to address newly-identified needs, services, treatment, and funding options. Documents changes in the care plan maintained in the medical management system. Evaluates case management outcomes, assessing the individual beneficiary's satisfaction and compliance with the care plan. Prepares and presents cases involving high-profile or sensitive issues to the Medical Director for review. Functions as an advocate for the beneficiary by ensuring access to necessary care and maintaining Beneficiary’s safety, locating specialized services outside the network by identifying providers, exploring nature of services offered, and facilitating process. Supports beneficiaries by providing TRICARE and community resource information and internal care referrals as needed to meet care plan goals. Understands, administers the TRICARE Specialty Program benefits, including program registration, enrollment, authorizations, and screening for high risk factors indicating appropriateness for catastrophic case management services. Monitors and provides direction to non-clinical staff. Regular and reliable attendance is required.