Lucent Health Case Management Division provide high quality case management services in a comprehensive health care risk management environment. Our case managers are responsible for providing comprehensive and clinically appropriate case management services telephonically to clients with chronic or catastrophic healthcare needs. Case Managers will be required to adhere with CMSA Standards of Practice, internal Policies and Procedures, and AAHC/URAC guidelines in the performance of their duties.

Minimum Education Licensure and Professional Certification requirement:

· Bachelor’s degree required.

· Five or more years Clinical Nursing Experience including psychiatric/substance abuse experience, UM or Case Management Certification

· Current/Active - Unrestricted Nursing License(and ability/willingness) to get multiple state licenses) or, equivalent combination of education and experience.

· Current Nursing License (RN) and, ability and willingness to get multiple state licenses, knowledge of the medical insurance industry, medical terminology, system hierarchies, medical care and treatment, and claims processing.


· Once appropriate cases have been identified Case Managers shall be responsible for contacting patients to explain Case Management and the associated process.

· Case Managers shall determine individual needs based on factors such as Medical Condition, Psychological Condition, work history and situation, any payer complications, external resources. Additional pertinent factors shall also be considered.

· Plan Development: Once assessment has been completed the Case Manager shall develop a plan that coordinates the appropriate treatment considering the facts of the assessment.

· The Case Manager shall provide the plan member with data to make informed decisions and should suggest alternative forms of treatment or contingencies where possible.

· The Case Manager will facilitate communication between the member and the care team and obtain approval from all parties whenever possible (member, family, providers, and payers). The plan should consider both maximize benefit to the member, while keeping cost as minimal as possible.

Minimum Experience Required

· 1-2 years previous health insurance claims experience.

· Claims pricing (Network, Medicare, RBP (Ref. Based Pricing) experience.

· Strong understanding of claims analyst process and procedures skills.

Required Skills and Abilities

· Has the skills to proficiently use a computer and associated databases and software applications.

· Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to accurately write routine reports, and correspondence. Ability to speak effectively before groups of customers or employees of the organization.


· Implementation: Once the plan has been approved by the member, the Case Manager should act as liaison between all parties.

· The primary goal is providing excellent care based on the decided upon plan to ensure that the desired outcome is reached.

· Evaluation of the Plan: Constant re-evaluation is required to ensure the plan is performing as designed, and to the expectations of all parties.

· The Case Manager shall continuously re-assess the plan and suggest changes where necessary.

· Case Managers shall also assist in Identification and Selection, and Termination of the Case Management process as able in cooperation with Claim Analysts.

Lucent Health is an Equal Opportunity Employer.