The RN Care Manager is responsible for the coordination of services for members who meet established criteria, with an emphasis on education/self-management and promoting quality care and cost effective outcomes. The Care Manager uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, evaluate Member status, discharge Members and fully document the individualized member care management process and outcome. The Care Manager is responsible for the management and oversight of a caseload of moderate - high risk Members with complex medical/psychosocial needs.
Uses a collaborative process and serves as a liaison between the participant, family and significant others, physician(s) and other members of the treatment team. Develops prioritized goals and health actions that assist participants with the implementation of appropriate self-directed care decisions and support improvement in health and self-reliance. Advocates for members and families by helping them to coordinate care and navigate resources throughout the healthcare system.
Using established criteria, analyzes and evaluates referrals for potential enrollment of Members into Care Management Program(s). Conducts assessments to obtain information for a participant-centered plan of care and determination of acuity level, functional status, . Obtains consent forms necessary for candidates accepted into the Care Management Program.
Applies established criteria for discharge and discharges the Member from the Care Management Program(s) when the criteria are met. When applicable, applies criteria for discontinuing use of remote monitoring equipment.
Conducts all care management activities, including documentation, in accordance with established departmental policies and procedures. Complies with all Clinical Management and corporate policies and procedures.
Builds relationships with members, their families, and implements interventions that move assigned members toward goals of improved knowledge, self-management, and long term care outcomes of stabilization.
Identifies and reports quality of care issues in accordance with established departmental policies and procedures. Maintains member confidentiality at all times.
Attends company and departmental meetings and training sessions as required.
Strong communication skills and the ability to positively interact with customers, peers, leadership, family members, caregivers, visitors, contracted agencies/personnel and the general public.
Knowledge of NCQA standards for Population Health Management for health plan accreditation, , DMAA standards for disease management and CMSA Standards of Practice for Case Management, Act 68, CMS and ERISA.
Maintains knowledge of evidence based guidelines for chronic conditions/care management.
Knowledge of clinical and managed care principles and operations.
Knowledge of current and emerging medical treatment modalities and best practice guidelines with the ability to analyze and interpret medical and benefit coverage interrelationships.
Knowledge of adult learning principles, motivational interviewing and intrinsic coaching techniques.
Superior clinical process, critical thinking, and problem solving skills; and ability to handle critical situations.
Excellent written, oral communication, listening, and organizational skills.
Ability to use computer system while conversing telephonically
Able to demonstrate strong customer service skills, including tact and diplomacy, both in person and telephonically when communicating with internal and external customers
Ability to appropriately prioritize workload and assignments and perform accurate, detailed and timely completion of assigned duties.
Ability to work autonomously and as part of an interdisciplinary team
Demonstrates sound judgment that affirms the rights and responsibilities of Member’s, families, health care professionals and health care organizations.
Ability to operate a personal computer (PC), including proficiency in Microsoft Office Products.
At least five (5) years’ recent/related experience; care management, home health, medical/surgical and/or critical care preferred. Additional experience related to specialized positions (Oncology, Transplant, Maternity) will also be considered.
Education, Certification, and Licenses:
Registered Nurse with active licensure in home state; additional state’s licensure as needed/required to meet customer needs.
Case Management certification preferred. Related certification (Chronic Care Professional, Certified Diabetic Educator) also accepted.
Subsequent to completing three (3) years in the position, the incumbent must obtain national certification as a case manager.
Possession of a valid driver’s license and the ability to travel to provider, facility, employer group and/or member locations using own vehicle, if appropriate.