The Telephonic Nurse Case Manager I performs care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans. This involves ensuring member access to appropriate services and facilitating authorizations and referrals within the benefits structure.

The Reviewer scrutinizes reports of investigations submitted by Field Investigators and Record Searchers to ensure accuracy, completeness, and timely submission to the customer. Responsibilities include conducting thorough reviews of background investigations, providing guidance to field staff, and maintaining quality and production standards.

The specialist provides non-clinical support to Medical Management and/or Operations areas, primarily by gathering clinical information to determine appropriate case assignment, such as utilization management or case management. Responsibilities also include providing network information, assisting with complex cases, acting as a liaison, maintaining databases, and preparing reports, while explicitly excluding utilization management review activities requiring clinical interpretation.

The specialist is responsible for improving inpatient clinical documentation by concurrently reviewing medical records to ensure accuracy based on clinical evidence and ICD-10-CM coding guidelines. This involves identifying documentation enhancement opportunities and querying physicians to support more specific and accurate diagnoses.