Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.
Responsibilities:
Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short- and long-term goals, treatment, and provider options.
Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes.
Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio-economic needs of clients.
Provide patient and provider education.
Facilitate members’ access to community-based services.
Monitor referrals made to community-based organizations, medical care, and other services to support the members’ overall care management plan.
Actively participate in integrated team care management rounds
Identify related risk management quality concerns and report these scenarios to the appropriate resources.
Case load will reflect heavier weighting of complex cases than Care Manager I, commensurate with experience.
Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems.
Direct care to participating network providers.
Perform duties independently, demonstrating advanced understanding of complex care management principles.
Participate in case management committees and work on special projects related to case management as needed.
Education/Experience:
Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community setting and 1+ years of case management experience in a managed care setting. Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e., InterQual, NCCN) and government sponsored managed care programs.
Licenses/Certifications:
Current state’s RN license
Day-to-Day Responsibilities:
Review/research assigned members.
Contact the member the day before to confirm visit and set up telehealth meeting invite.
Explain to members that the visit may take anywhere between 2-3 hours.
Perform assessment either via telehealth (video AND audio) or in-person (in member’s home)
Contact PCP office to confirm diagnosis and report any abnormal findings.
Upload the MN signature page within one business day for attempts to MD signature to begin.
Complete the assessment documentation.
Coordinate assessment finding needs ex—send referrals for DME items covered under the member’s core benefit, initiate non-waiver items/services.
Once the MD signature is received—assessing RN is to sign the MNLOC (assessment) within 24 hours.
Process continues from this point as needed.
Education/Experience:
Texas Requirements:
Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred.
2+ years of clinical nursing or case management experience in a clinical, acute care, managed care, or community setting.
2+ years’ experience collaborating with people with disabilities and vulnerable populations who have chronic or complex conditions in a managed care environment.
Experience with medical decision support tools (i.e., InterQual, NCCN) and government sponsored managed care programs. Other state specific requirements may apply.
Licenses/Certifications:
Current state’s RN license.
Seniority level
Mid-Senior level
Employment type
Part-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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