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Coordinates the care and services of selected member populations across the continuum of illness. Promotes effective utilization and monitors health care resources. Assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes. Works with the Supervisor / Manager of Case Management to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Member.
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 case management objectives.
Manages 60 to 80 active cases based on case intensity and acuity. Specialty Case 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.
Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
Maintains accurate records of case management activities in the EMMA System using clinical guidelines.
Coordinates community resources with emphasis on medical, behavioral and social services. Applies case 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.
Specific state specialty programs may require initial and annual training hours related to the area of specialty.
Required A High School or GED
Preferred A Bachelor's Degree in nursing or related field
Required Other Illinois's Children with High Needs program requires a bachelor's degree in nursing, social sciences, social work 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 management experience
Intermediate Ability to drive multiple projects
Intermediate Ability to multi-task
Intermediate Ability to work in a fast paced environment with changing priorities
Intermediate Ability to work independently
Intermediate Demonstrated time management and priority setting skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate 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
Ability to effectively present information and respond to questions from peers and management
Intermediate Ability to implement process improvements
Licenses and Certifications: A license in one of the following is required:
Required Licensed Registered Nurse (RN)
Preferred Certified Case Manager (CCM)
Required Beginner Microsoft Excel
Required Beginner Microsoft Word
Required Beginner Healthcare Management Systems (Generic)