Facebook · 3 months ago
RN Navigator Case Manager - MCC II (Juno Beach, Florida)
W@H Florida
Full-time
Hybrid
Mid Level
4+ years expFacebook is a leading company in the healthcare sector, and they are seeking an RN Navigator Case Manager to enhance care coordination and improve the quality of life for clients. The role involves active case management, telephonic support for members, and collaboration with healthcare professionals to ensure effective care delivery.
Computer Software
Responsibilities
Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals
Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions
Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits
Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions that consist of: intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement
Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans
May identify, initiate, and participate in on-site reviews
Serves as member advocate through continued communication and education
Promotes enrollment in care management programs and/or health and disease management programs
Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members
Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines
Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.)
Participates in data collection/input into system for clinical information flow and proper claims adjudication
Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal)
Maintains current knowledge of contracts and network status of all service providers and applies appropriately
Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services
Qualification
Required
An active, unrestricted RN license from the United States and in the state of hire OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing
Four years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery; OR four years utilization review/case management/clinical/or combination; two of the four years must be clinical
Working knowledge of word processing software
Knowledge of quality improvement processes and demonstrated ability with these activities
Knowledge of contract language and application
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated customer service, organizational, and presentation skills
Demonstrated proficiency in spelling, punctuation, and grammar skills
Demonstrated oral and written communication skills
Ability to persuade, negotiate, or influence others
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Microsoft Office
URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager
Preferred
Two years case management experience
Strong computer skills and ability to work independently from home
Benefits
401(k) retirement savings plan with company match.
Subsidized health plans and free vision coverage.
Life insurance.
Paid annual leave – the longer you work here, the more you earn.
Nine paid holidays.
On-site cafeterias and fitness centers in major locations.
Wellness programs and healthy lifestyle premium discount.
Tuition assistance.
Service recognition.
Incentive Plan.
Merit Plan.
Continuing education funds for additional certifications and certification renewal.
Company
The Facebook company is now Meta. Meta builds technologies that help people connect, find communities, and grow businesses.
10001+ employees
H1B Sponsorship
Facebook has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2022 (942)
2021 (5811)
2020 (4476)
Funding
Current Stage
Late StageLeadership Team
Arunava Chatterjee
Executive Director of Ghost Black Operations & CEO & CTO
Shubhra Gupta
CEO
Recent News
Business Live
2025-11-03
2025-11-01
Company data provided by crunchbase