The telephonic RN Case Manager position is responsible for utilizing the nursing process in the development of member treatment plans. The Case Manager will establish member goals and implement interventions to optimize member health care across an assigned patient case- load in order to promote high quality healthcare appropriate for the member's clinical needs.
Improve member health outcomes by successfully managing a member caseload from a variety of care management referral sources.
Conduct telephonic member assessments to identify member care coordination needs; develop, with member and provider as appropriate, a specific care management plan to address member goals and interventions as identified during assessments.
Manage members with chronic illness, co-morbidities, and/or complex health conditions to ensure the member receives quality health care in the most cost- effective and efficient delivery of healthcare benefits.
Provide member and/or caregiver self- management strategies and ensure member receives appropriate level of post -care education to include education on condition(s), medication, benefits, and resources to optimize highest level of function.
Identify potential gaps in member care through education, empowerment and/or motivational interviewing techniques.
Coordinate internal and external resources to meet identified needs by assisting member with obtaining any DME supplies, pharmacy referrals, and / or community resources.
Interfaces with Medical Directors and other interdisciplinary team members in the development of care management treatment plans.
Familiarity with the quality management process and customer- focus care to improve STARS and HEDIS outcomes.
Continues professional development by attending relevant educational programs at least annually.
Ability to meet and/ or exceed established productivity metrics and standards.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
Nursing diploma or Associates degree in nursing required.
Current, unrestricted RN license in Virginia required.
Bachelor's degree in nursing or related field preferred.
Certification in Case Management (CCM) preferred.
Two (2) to four (4) years of related clinical experience required.
One (1) to three (3) years case management experience preferred.
Managed care experience in Medicare case management preferred.
Experience in med surgical, preventive care, chronic condition education, homecare, critical care and public health preferred.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
Must have basic computer knowledge, typing ability, and proficiency in Microsoft Office products.
Effective written and verbal communication skills. Ability to work independently yet remain engaged with team members as needed to meet performance metrics.
Effective organizational skills, ability to prioritize multiple tasks while maintaining flexibility.
Knowledge of Case Management and Disease Management principles.
Knowledge of medical surgical principals, discharge planning, chronic diseases and clinical programs.
Knowledge of HIPAA, American Disability Act, Clinical ethics, COB rules and Medical Policy.
Familiarity with InterQual criteria, crisis call interventions, evidence-based guidelines and alternate care.
Knowledge of educational assessments and learning strategies.
Work is performed in an office setting and or hybrid of a work from home model with productivity and quality expectations. Work requires sitting for extended periods of time, talking on the telephone and typing on the computer. Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.