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The Case Manager RN is responsible for managing members experiencing complex or catastrophic illness, injury and/or specialty illnesses such as diabetes, HIV, transplant, etc, to insure cost effective and efficient utilization of health services. She/he acts as a member advocate, seeking and coordinating creative solutions to member's health care needs without compromising quality of outcomes.
Responsibilities:
PRIMARY RESPONSIBILITIES:
1. Obtains an accurate member history.
2. Assesses clinical information to develop care plans including a member support system.
3. Establishes short and long term goals in collaboration with the member that meet the member's needs and the referral source's requirements.
4. Establishes working relationships with referral sources and community resources.
5. Communicates care objectives to appropriate individuals/departments/referral sources.
6. Assessment of biopsychosocial factors.
7. Identifies members with potential for high risk complications and coordinates the appropriate treatment in conjunction with the member and the health care team.
8. Collaborates with the member's PCP and specialists in the development of the plan of care to ensure that members' physical needs are addressed
9. Provide case management and/or disease management services to members, as identified by the health plan's CI3 list
10. May be required to conduct field visits.
11. May be required to perform Pre Certification duties and responsibilities as assigned and required by the Plan
12. Acts as an advocate for an individual's health care needs.
13. Reviews benefit systems and cost benefit analysis.
14. Evaluates the quality of necessary medical services.
15. Utilizes criteria for authorizing appropriate clinical services.
16. Identifies members that would benefit from an alternative level of care. 17. Acquires data and evaluates necessary health services for cost containment.
18. Documents effectiveness of case management services.
19. Identifies the need for assistive devices/adaptive equipment needed for members.
20. Conducts skills assessment, planning, implementation, coordination, monitoring and evaluation.
21. Requests direction from appropriate supervisor(s) on complex issues. 22. Utilizes leadership skills for non-clinical team members.
23. Collaboratively works with other departments.
24. Participates in Quality Improvement processes.
25. Serves on internal and external committees.
26. Maintains member confidentiality.
27. Other duties as requested or assigned.
Qualifications:
EDUCATION AND EXPERIENCE:
Education Required: - Current RN state license required.
Preferred: - Bachelors or Masters Degree. .
Years and Type of Experience Required:Required: - Four years experience in health care, case management, discharge planning or behavioral health.
Preferred: - Experience working on the community level and with community agencies preferred. Specific Technical Skills Required:
Preferred:Certifications or Licensure Required: - Must possess a valid driver's license and access to a motor vehicle. Preferred: - Certified case managers preferred.
Other Required: - Computer literate. - Excellent verbal and written communications skills. - Strong decision making skills. - Ability to provide services in an environment that involves multiple health care systems. - Ability to interact with all relevant components of the health care system. - Ability to provide services that deal with the individual's broad spectrum of needs. - Self-starter with ability to handle multiple projects at one time. - Appreciation of cultural diversity and sensitivity towards target population. - Bilingual a plus.
PHYSICAL REQUIREMENTS: - Must be able to operate a computer. - Must be able to operate (and communicate via) a telephone. - Must be able to sit for long periods of tim
