RN Nurse Case Manager

Position Summary:

·         The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

·         Requires an RN with unrestricted active license in VA or compact license.

Duties:

Assessment of Members:

·         Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services.

·         Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address

·         complex clinical indicators which impact care planning and resolution of member issues.

·         Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.

·         Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.

Enhancement of Medical Appropriateness and Quality of Care:

·         Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits

·         Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes.

·         Identifies and escalates quality of care issues through established channels.

·         Ability to speak to medical and behavioral health professionals to influence appropriate member care.

·         Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.

·         Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.

·         Helps member actively and knowledgably participate with their provider in healthcare decision-making.

·         Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.

Monitoring, Evaluation and Documentation of Care:

·         In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals.

·         Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

·         Majority of time is spent on telephonic outreach and documentation in a clinical case management platform.

Experience:

·         3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

·         Experience preferred managing chronic conditions, such as diabetes, hypertension, and asthma.

·         Healthcare and/or managed care industry experience required.

·         Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

·         Effective communication skills, both verbal and written.

·         Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

·         Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.

·         Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

·         Typical office working environment with productivity and quality expectations.

Education:

·         RN with current unrestricted state licensure in VA or compact license.

·         Case Management Certification CCM preferred