[Hiring] Behavioral Health RN Case Manager @Imagine360

Role Description

Imagine360 is seeking a Behavioral Health RN Case Manager to join the team!

The Behavioral Health RN Case Manager is responsible for delivering case management services to individuals covered by group health plans administered by Imagine360, drawing on nursing education, clinical experience, and professional judgment. The RN serves patients with medical, behavioral health, mental health, and/or neurodevelopmental disorder needs. They adhere to department criteria, collaborating with physicians, providers, members, and other stakeholders to:

• Assess, plan, coordinate, monitor, evaluate, and advocate for necessary options and services to address comprehensive health needs of individuals and families.
• Leverage communication and resources to enhance quality and cost-effective outcomes.
• Act as a liaison to providers, physicians, and members.
• Receive member referrals from non-Behavioral Health Case Managers and Disease Management clinicians.

The Registered Nurse operates within the scope of nursing practice while fulfilling these responsibilities.

Position Start Date: January 2027

Position Location: 100% remote

Responsibilities

• Identify, collect, process, and manage data to perform the Case Management process by utilizing Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures.
• Conduct comprehensive clinical assessments according to established policies and procedures to identify and provide appropriate care and coordination of behavioral health, mental health, neurodevelopmental disorder diagnoses.
• Manage members with behavioral health, mental health, neurodevelopmental disorder diagnoses, and for members with medical diagnoses that also have behavioral health, mental health, neurodevelopmental disorder diagnoses.
• Utilize clinical knowledge, expertise, and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures, and/or treatment.
• Assess the need for and collaborate with community resources for members in case management.
• Use assigned software accurately to document and complete all steps of review of medical necessity and case management processes, including time slips.
• Facilitate the Patient Satisfaction Surveys.
• Assess for cost savings and document the cost savings in assigned software platform.
• Appropriately escalate complex cases to Supervisor, IDCT, or designee as needed.
• Perform essential activities of case management while maintaining members' confidentiality, safety, advocacy, adherence to ethical, legal, accreditation, and regulatory standards.
• Perform assessments of each member to identify Case Management needs.
• Consistently exercise discretion and judgment to analyze, interpret, make deductions, and then decide what actions are necessary based on the varying facts and circumstances of each individual case.
• Determine measurable goals utilizing motivational interviewing and behavior change model and coach clients while monitoring self-care practices.
• Utilize industry standard tools to guide individuals with chronic/ongoing health conditions through coaching, assessments, listening, and other techniques as appropriate.
• Execute activities or interventions to achieve the goals in the plan.
• Organize, integrate, and modify the resources needed to reach the goals in the plan.
• Monitor all information from all relevant sources in the plan and its activities and services to determine the plan's effectiveness.
• At repeated intervals, evaluate to determine ultimate effectiveness of plan and modify plan appropriately to meet the goals.
• Research medical procedures, treatments, and coding when necessary.
• Measure the outcomes of interventions.
• Adhere to practicing the care management core components throughout the continuum of care:
• Case Management Concepts
• Case Management Principles and Strategies
• Psychosocial and Support Systems
• Healthcare Management and Delivery
• Healthcare Reimbursement
• Vocational Concepts and Strategies
• Act as a role model in demonstrating the core values in customer service delivery.
• Provide timely and thorough follow-up with internal and external customers.
• Appropriately escalate difficult issues up the chain of command.
• Serve on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
• Recognize and alert appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
• Perform self-quality monitoring to develop and execute plans to meet established goals.
• Provide ongoing feedback to help optimize quality performance.
• Collaborate with others and cross-departmentally to improve or streamline procedures.
• Develop new or improve current internal processes to improve quality.
• Attend and participate in team meetings, trainings, and other job specific events as required.
• Communicate (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives, and stop loss as needed.
• Communicate professionally and effectively.
• Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and procedures.
• Participate in the Quality Management Program via collecting and adhering to performance metrics.
• Complete HIPAA Training Annually.
• Perform all tasks in accordance with HIPAA/PHI guidelines.
• Complete duties in accordance with scope of licensure and certifications held or requested.
• Perform other duties and projects as assigned.

Qualifications

• Nursing degree from an accredited college, university, or nursing school.
• Bachelor's degree in nursing preferred but not required.
• 3+ years' experience working with Behavioral/Mental Health patients or programs.
• 1+ years in Case Management, discharge planning or managed care experience or transferable nursing experience and skills.
• Experience with Utilization Management and standardized criteria.
• Experience working in a URAC accredited Case Management program.
• Experience working within an insurance agency or TPA specializing in employee benefits and self-funded medical plans.

Skills and Abilities

• Ability to work independently in a home office environment.
• Computer skills include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, and navigation using the internet.
• Ability to resolve problems independently and demonstrate ability to multi-task.
• Strong written, oral, and telephonic communication skills.
• Strong presentation skills.
• Ability to demonstrate a commitment to building new skills and fostering a positive work environment.
• Demonstrated organizational skills, problem-solving, analytical skills, and detail oriented.
• Demonstrated ability to prioritize workloads, multi-task, and manage priorities to meet deadlines.
• Ability to maintain the confidentiality of protected health information in compliance with HIPAA regulations.

License and Certifications

• Current, active, and unrestricted compact Registered Nurse license. Must maintain CEUs as required by the State Board of Nursing.
• Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.
• Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment.

Benefits

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

Company Description

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CVs submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation.