Job Description: Position Purpose: 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.
Education/Experience: Graduate from an Accredited School of Nursing. Bachelors 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 states RN license.
Texas Requirements
Education/Experience: Graduate from an Accredited School of Nursing. Bachelors 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 working 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.
Job Duties
" 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 member 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
Walk me through the day to day responsibilities of this the role and a description of the project:
Follow up with members, completing Task assigned
Describe the performance expectations/metrics for this individual and their team:
Provide support to medical, behavioral and social support staff to determine needs, eligibility and services for members.
Conduct screening and risk assessment interventions per program guidelines. Job Responsibilities: Identify special needs members through the completion of health screens and other resources.
Work with community outreach/member advocates to coordinate member care.
Educate providers and community resources on program components and available support services. Educate members with special needs to foster compliance with program and positively impact outcomes.
Assist with modification and management of care plans, medical consenter or caregiver, Department of Family and Protective Services (DFPS) caseworker and family, if applicable, as well as the managing physician
Internal/External Groups with which the Candidate will interface: Required Skills/Experience: Preferred Skills/ Experience: 1. RN (1 year is ideal, but manager is willing to be flexible) 1. Case Management 2. Computer skills, phone skills 2. Home Health Experience 3. 3. Education Requirement: RN Education Preferred: Software Skills Required: Computer literacy, needs to be able to work independently Required Certifications: RN Required Testing:
Seniority level
Entry level
Employment type
Contract
Job function
Health Care Provider
Industries
Hospitals and Health Care
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