Quartz is seeking a licensed RN to join our organization as a Registered Nurse (RN) Case Manager. This role is responsible for conducting clinical review of authorization requests to identify appropriate types and optimal levels of patient care. This role also facilitates referrals between health plan members, participants, primary care physicians and other health care providers.
Utilize clinical judgment and knowledge of established standards to make coverage determinations based in individual member circumstances
Conduct prospective, concurrent, and retrospective medical reviews for coverage determinations of managed care members
Review medical records, conduct telephone assessments, and patient/nurse/physician interviews, and provide referrals to appropriate agencies, as needed
Investigate and facilitate all alternatives to services requested when specific requests cannot be authorized
Analyze data for case selection process utilizing resources such as claims, hospital discharge, pharmacy, and utilization management data as well as data supplied by other resources such as purchasers, member or caregiver, and practitioners
Care Management - establish objectives, goals and actions designed to meet patient’s needs and monitor the care plan to ensure effectiveness and appropriateness of services; practice conflict resolution strategies, as needed
Obtain accurate and detailed clinical information from appropriate sources to facilitate clinical review of cases; maintain information for reporting purposes
Maintain confidentiality and adhere to the professional standards and ethics of the healthcare field and managed care industry
Serve as the medical liaison between contracting staff and case managers, interpreting contractual language to determine payment issues and collaborating with all parties to resolve contract issues based on medical appropriateness, as needed.
Bachelor’s Degree in nursing or related field
State of Wisconsin RN license
2-3 years of RN case management experience in a clinical and/or inpatient setting
Valid Driver’s license with the ability to travel, as necessary, within the designated service area
State of Illinois RN license is preferred, or ability to obtain upon hire
Certified Case Manager, or related certification, preferred
Working knowledge of managed care as it relates to contracting in health insurance, per diems, DRG’s CPT and ICD-9 coding
Exceptional customer service skills: Understand needs of culturally diverse populations including ability to evaluate for literacy and literacy needs
Strong written and verbal communication skills interacting with individuals internally and externally
Strong independent, critical thinking skills to understand individual and operational problems and identifying appropriate solution(s)
Applicants will work full-time from our office in Onalaska, WI. Quartz offers an excellent benefit and compensation package, opportunity for professional growth and a professional culture built upon the foundation of Respect, Responsibility & Relationships.
Quartz values and embraces diversity and is proud to be an Equal Employment Opportunity, Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity or expression, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.
Internal Number: 1458
Quartz is a health plan services company. The company manages the nationally recognized provider-sponsored health insurance plans – Gundersen Health Plan, Physicians Plus and Unity Health Insurance, which are co-owned by Gundersen Health System, UnityPoint-Meriter and UW Health. As a third-party administrator, Quartz also services self-funded health plans. Through an extensive provider network, Quartz focuses on local community-based health care and services over 300,000 customers who live in southern and western Wisconsin, parts of Illinois, Iowa and Minnesota from offices located in Middleton, Madison, Sauk City and Onalaska, Wisconsin.