Coordinates the care and services of selected member populations across the continuum of illness. Promotes effective utilization and monitors health care resources. Completes clinical assessments on members to determine the necessity of educational health needs based on their disease process, and to monitor the level of adherence. Assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes. Assess, plans, implements, coordinates, monitors and evaluates services and outcomes to maximize the health of the Member.
Department: Health Services State
Reports to: Mgr, Care Management
- Provides telephonic member assessment as the result of inbound and outbound member phone calls
- In conjunction with the PCP and member, completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the member's need for alternative services. Assess short-term and long-term needs and establishes care management objectives.
- Manages 60 members based on case intensity and acuity. Specialty Care Manager case loads may vary.
- Interacts continuously with member, family, physician(s) and other providers utilizing clinical knowledge and expertise to determine medical history and current status. Assess the options for care including use of benefits and community resources to update the care plan.
- Promote and encourage members regarding adherence to their care plan and treatment as set by the caregiver. Provide referrals as appropriate
- Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
- Maintains accurate records of care management activities in the medical management system, using clinical guidelines.
- Coordinates community resources with emphasis on medical, behavioral and social services. Applies care and disease management standards and maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
- Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
- Schedules or facilitates scheduling appointments and follow-up services
- Requests consultation and diagnostic reports from network specialists
- Contacts members to remind them about upcoming appointments and/or missed appointments
- Participates in monthly chart audits.
- Performs special projects as assigned.
- Case load may differ by state and/or location based on contract requirements, membership, plan and/or operational best practice
- Some states and/or locations may require nurses to occasionally travel to facility or inpatient bedside to conduct assessments or face to face visits
- Some state/market care managers may be responsible for Utilization Management and uses prescribed criteria to provide timely, appropriate, and medically necessary service authorizations.
- Additional licensures may be required in multiple states based on business needs.
- Required A High School or GED
- Preferred A Bachelor's Degree in nursing or related field
- Required 2 years of experience in a clinical acute care position(s), preferably in home health, physicians office or public health
- Required 1 year of experience in current case or disease management experience
Licenses and Certifications:
- Intermediate Ability to drive multiple projects a plus
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
- Intermediate Demonstrated negotiation skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to implement process improvements
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Preferred Certified Case Manager (CCM)
- Required Intermediate Microsoft Excel Intermediate knowledge and skills of MS Office including Excel, Word and Outlook Express
- Required Intermediate Microsoft Word
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Outlook
- Preferred Other Bilingual skills