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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: - Obtains an accurate member history. - Assesses clinical information to develop care plans including a member support system. - Establishes short and long term goals in collaboration with the member that meet the member's needs and the referral source's requirements. - Establishes working relationships with referral sources and community resources. - Communicates care objectives to appropriate individuals/departments/referral sources. - Assessment of biopsychosocial factors. - Identifies members with potential for high risk complications and coordinates the appropriate treatment in conjunction with the member and the health care team. - Collaborates with the member's PCP and specialists in the development of the plan of care to ensure that members' physical needs are addressed. - Provide case management and/or disease management services to members, as identified by the health plan's CI3 list. - May be required to conduct field visits. - May be required to perform Pre Certification duties and responsibilities as assigned and required by the Plan. - Acts as an advocate for an individual's health care needs. - Reviews benefit systems and cost benefit analysis. - Evaluates the quality of necessary medical services. - Utilizes criteria for authorizing appropriate clinical services. - Identifies members that would benefit from an alternative level of care. - Acquires data and evaluates necessary health services for cost containment. - Documents effectiveness of case management services. - Identifies the need for assistive devices/adaptive equipment needed for members. - Conducts skills assessment, planning, implementation, coordination, monitoring and evaluation. - Requests direction from appropriate supervisor(s) on complex issues. - Utilizes leadership skills for non-clinical team members. - Collaboratively works with other departments. - Participates in Quality Improvement processes. - Serves on internal and external committees. - Maintains member confidentiality.
Qualifications:
EDUCATION AND EXPERIENCE:
Education
Required: - Current RN state license required. - This position is seeking an OB focused Case Manager.
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. - OB Experience strongly preferred.
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 time
