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 is a case manager serving 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. They leverage communication and resources to enhance quality and cost-effective outcomes, acting as a liaison to providers, physicians, and members. The RN will receive member referrals from non-Behavioral Health Case Managers and Disease Management clinicians to support the Behavioral Health needs of those members. The Registered Nurse operates within the scope of nursing practice while fulfilling these responsibilities.
Position Start Date: January 2027
Position Location: 100% remote
Responsibilities include but are not limited to:
- Identify, collect, process, and manage data to perform the Case Management process by utilization Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures
- Conducts 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.
- Uses 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 escalates complex cases to Supervisor, IDCT, or designee as needed.
- Performs essential activities of case management while maintaining members' confidentiality, safety, advocacy, adherence to ethical, legal, accreditation and regulatory standards.
- Performs assessments of each member to identify Case Management needs.
- Consistently exercises 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.
- Determines measurable goals utilizing motivational interviewing and behavior change model and coaches' clients while monitoring self-care practices.
- Utilizes industry standard tools to guide individuals with chronic/ongoing health conditions through coaching, assessments, listening, and other techniques as appropriate.
- Executes activities or interventions to achieve the goals in the plan.
- Organizes, integrates, and modifies the resources needed to reach the goals in the plan.
- Monitors all information from all relevant sources in the plan and its activities and services to determine the plan's effectiveness.
- At repeated intervals, evaluates to determine ultimate effectiveness of plan and modifies plan appropriately to meet the goals.
- Research medical procedures, treatments, and coding when necessary.
- Measures the outcomes of interventions.
- Adheres 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.
- Customer Service
- Acts as a role model in demonstrating the core values in customer service delivery.
- Provides timely and thorough follow-up with internal and external customers.
- Appropriately escalates difficult issues up the chain of command.
- Quality Assurance
- Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
- Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
- Performs self-quality monitoring to develop and execute plans to meet established goals.
- Provides ongoing feedback to help optimize quality performance.
- Collaborates with others and cross-departmentally to improve or streamline procedures.
- Develops new or improves current internal processes to improve quality.
- Attend and participate in team meetings, trainings, and other job specific events as required.
- Communicates (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives and stop loss as needed.
- Communicates 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.
Areas of Responsibility Scope of Practice:
- In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making and patient education. The scope of practice includes, but is not limited to:
- Evaluating clinical data
- Assessment and evaluation of the acquired clinical data to assess for appropriateness of treatment based on Imagine360 clinical guidelines
- Coordination of treatment plans, interventions, and outcome measurements
- Rationale for the effects of medication and treatments
- Provide patient education and educational resources.
- Accurately report:
- Administration of medication and treatments
- Client response
- Contact other health care team members.
- Respect the client's right to privacy by protecting confidential information.
- Promote and participate in education and counseling to a participant based on health needs.
- Clarify any treatment believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner.
- The RN will have knowledge and practice the core components of Case Management that include:
- Case Management Concepts
- Principles of Practice
- HealthCare Management & Delivery
- Healthcare Reimbursement
- Psychosocial Aspects of Care
- Rehabilitation
- Professional Development & Advancement
- Quality and Outcomes Evaluation and Measurement
- Ethical, Legal, and Practice Standards
Required Experience/Education:
- 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 transferrable 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 CEU's 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.
What can Imagine360 offer you?
- 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
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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/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**
