Location: Rocky Point
Reports to: VP HS
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.
- 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.
- 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.
- Outreaches to members telephonically and/or in-person and coordinates member's case management services.
- 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.
- Requests consultation and diagnostic reports from network specialists.
- 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.
- Required An Associate's Degree in nursing or graduation from Diploma Nursing School
- 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
- Preferred 1 year of experience in current case management experience
- Preferred 2 years of experience in appropriate experience and qualifications required to assessing members individual needs
- Preferred 2 years of experience in physical health, aging and loss, appropriate support services in the community, frequently used medications and their potential side effects, depression, challenging behaviors, Alzheimer's disease and other disease related dementias, behavioral health, and issues related to accessing and using durable medical equipment, as appropriate.
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
- 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 Beginner Microsoft Excel Intermediate knowledge and skills of MS Office including Excel, Word and Outlook Express
- Required Beginner Microsoft Word
- Required Beginner Healthcare Management Systems (Generic)
- Required Beginner Microsoft Outlook
- Preferred Other Bilingual skills