About the job
Job Description
Get To Know Us!
WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.
Key Job Details
- Availability for Monday to Friday 8:00am to 5:00pm Central Time
- Bilingual in Spanish required
What is your impact?
The RN Case Manager primary responsibility is to create, implement, and monitor treatment plans to assist patients/members in meeting their healthcare goals. You would use knowledge of healthcare and social services to assess needs and provide interdisciplinary care options in treatment planning for the member. This would include understanding the member’s healthcare benefits and healthcare best practices needed for effective treatment planning.
What Will You Be Doing
- Case Management process includes assessing the member’s health status and care coordination needs. Can include inpatient review and discharge planning, as well as possible outpatient management.
- Contact with patient, family, physicians, additional health care providers, and community resources. Contact with provider business offices and with the employer/client may also be required.
- Identification of alternative treatment plans, which would have to be approved by all parties. These alternative care plans will be based on quality care within cost containment guidelines, allowing available claims dollars to be used in the most judicious manner possible.
- Assessment of the clinical status and resultant sequela to coordinate the most appropriate service to meet the individual’s health care needs. The Case Manager will then monitor the health status and the impact of the treatment plan for each client. The Case Manager will be responsible for altering the care plan as deemed appropriate by the dynamic, ever-changing client needs.
- Identification of services, resources, providers, and facilities that could best serve members in a timely and cost-effective manner, to promote optimum value for the client and reimbursement source.
- Development and implementation of Case Management goals, both short and long term, with documented care plans.
- Utilize technology/resources to evaluate the cost-effectiveness of the elected treatment plan, pre-implementation and post-implementation. This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans.
- Accurate and timely reporting as deemed appropriate by each client member.
- Medical record review to determine medical necessity of requested services.
- Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions.
What You Must Have
- 5+ years related work experience with a professional background in clinical nursing and patient assessment.
- Bilingual in Spanish
- Related Bachelor’s degree or additional related equivalent work experience
- Graduate of an accredited school of nursing
- RN – Registered Nurse – State Licensure
- Compact State Licensure in good standing.
- 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
- New York state Registered Nurse licensure.
- 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.
- Ability to identify problems such as underutilization or overutilization of services
- Ability to promote and maintain quality care through analysis
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.
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.
About the job
Quality Review Nurse
Who are we?
Versant Health is one of the nation’s leading administrators of managed vision care, serving over 35 million of our clients’ members across the United States. Our purpose is to make healthy vision a reality for everyone by improving access to care and education in the communities we serve. Fueled by our mission to improve members’ lives with easy-to-use vision solutions rooted in choice value, and care, we believe that everyone has the power to become anything they set their sights on.
See how you can make a difference with the support of strong leadership and a team environment.
Versant Health: Making Healthy Vision a Reality for Everyone
What are we looking for?
The Quality Review Nurse works within the Utilization Management team to bring additional clinical expertise to the prior authorization and denial review processes. The Quality Review Nurse applies specific criteria and payer guidelines to ensure that all healthcare services provided are optimized for quality and timeliness of the care. This role serves as the clinical support person for the Utilization Management Team and as a subject matter expert (SME) for member friendly language and denial letter review.
Where you will have an impact
- Serve as a clinical resource to the Utilization Management Team
- Serve as a SME for member friendly language notification letters
- Provide quality clinical review and edits of all denial letters to ensure NCQA requirements are met
- Maintain a quality tracking log of all letters reviewed
- Quality Clinical Review of authorization requests
- Apply specific medical criteria and payer guidelines when reviewing clinical documentation for medical necessity
- Ensure services provided to eligible members are within the benefit plan and that appropriate contracted providers are being utilized
- Identify and refer cases for second level review when necessary
- Follow and apply all regulatory requirements for assigned markets
- Monitor reporting to track missing diagnosis codes and update prior authorization to reflect properly assigned diagnosis codes on a weekly basis
- Work closely with utilization management leadership to ensure the continual compliance of all QA/QI initiatives
- Contribute to a positive work culture by modeling excellence in both work ethic and team interactions
- Perform additional duties as assigned
What’s necessary to do the job?
- Graduate of an accredited Practical Nursing program required.
- 3+ years of related experience in utilization management required
- 3+ years of clinical experience in acute care required
- Proficiency in Microsoft Office suite required
- Active, unrestricted LNP or LVN license in state of residence, or compact state licensure required.
- Knowledge and experience in the insurance, health, or vision care industry perferred
HIPAA & Security Requirements
All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.
We offer a comprehensive and competitive total rewards package designed to support your health, financial well‑being, and work‑life balance. Benefits include medical, dental, and paid vision coverage; paid time off and company holidays; retirement savings with employer contribution; employee wellness resources; and professional development opportunities. Additional benefits may include flexible work arrangements, employee assistance programs, and other programs that support you both at work and beyond.
Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process.
Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.
Our purpose is to make healthy vision a reality for everyone by improving access to care and education in the communities we serve. Fueled by our mission to improve members’ lives with easy-to-use vision solutions rooted in choice, value, and care, Versant Health believes that everyone has the power to become anything they set their sights on.
Our team is guided by core Leadership Principles—Perspective, Care, Drive, and Ownership—which shape how we work, lead, and grow together.
Our Management Team is committed to fostering a strong and supportive culture, cultivating a thriving work environment, providing clear direction, optimizing resources, enabling innovative solutions, and driving meaningful results.