Care Mgmt Referral Analyst RN

Get To Know Us!

WebTPA, a GuideWell Company, is a healthcare third-party benefit administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. 

What is your impact?

The RN Referral Analyst position works in conjunction with and in support of the case management (CM) team, and assures the appropriate use of case management resources to accomplish the optimal quality outcomes. The above is accomplished through the use of organizational accepted criteria for determining appropriateness for opening and assigning a CM case. This determination includes level of care, discharge status, benefit analysis and needs of the Client as applicable. The RN Referral Analyst participates in ongoing departmental improvement, quality initiatives, and supports the strategic goals of Care Management.

What Will You Be Doing: 

• Monitor and review referrals received from Utilization Management authorization triggers, high-dollar claimant reports, emergency room utilization reports and internal referrals from other care management departments and any departments that handle case management workflow. Assesses and assigns cases for medical case management based on acuity, staffing levels and clinical information available. 

• Review clinical information supplied in UM authorizations, claims data/activity as part of the assessment process. Ensures additional documentation is uploaded to the case should documents and/or information need to be attached to a cases that is being referred. 

• If a referral is not appropriate to fully open for Case Management, but the referred member could benefit from an alternate outreach campaign or initiative, the Referral Analyst will assist with identification of alternate care outreach plans for that member. These alternate plans will be based on plan/group resources (e.g. MES outreach around a specific concern). 

Qualifications: 

• 5+ years related work experience with a professional background in clinical nursing and patient assessment. 

• Related BSN degree or additional related equivalent work experience 

• Graduate of an accredited school of nursing 

• RN - Registered Nurse - State Licensure 

• ICU experience with higher-acuity patients in a clinical setting. 10+ years of extensive experience in various medical-surgical units will be considered, in substitute.

• Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.

• Ability to collaborate with cross-operational areas within the organization.

What We Prefer:

• (CCM) Certified Case Manager

• Compact State Licensure in good standing.

• Prior experience in utilization management or case management preferred, preferably within the managed care environment

• Intensive care or higher-acuity patient experience preferred. 

• Knowledge of managed care in a self-funded employer population is preferred. 

What We Can Offer YOU!

To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance

• Income protection benefits: life insurance, Short- and long-term disability programs

• Leave programs to support personal circumstances

• Retirement Savings Plan includes employer contribution and employer match

• Paid time off, volunteer time off, and 11 holidays

• Additional voluntary benefits available and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ.

Physical/Environmental Activities

Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally 

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. 

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.