Job Description
RN Case Manager to perform field-based assessments for members
Position Summary:
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Healthcare. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.
Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources.
Duties:
Evaluation of Members: -Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred members needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating members benefit plan and available internal and external programs/services. Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. - Coordinates and implements assigned care plan activities and monitors care plan progress. Enhancement of Medical Appropriateness and Quality of Care: - Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review to achieve optimal outcomes. - Identifies and escalates quality of care issues through established channels. -Utilizes negotiation skills to secure appropriate options and services necessary to meet the members benefits and/or healthcare needs. - Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health. -Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. -Helps member actively and knowledgably participate with their provider in healthcare decision-making. Monitoring, Evaluation and Documentation of Care: - Utilizes case management and quality management processes incompliance with regulatory and accreditation guidelines and company policies and procedures.
Experience:
Case management and discharge planning experience preferred 2 years experience in behavioral health, social services or appropriate related field equivalent to program focus Managed Care experience preferred
Education:
Bachelor's degree or Associate's degree in nursing; Unrestricted RN licensure required in Virginia
Education
Bachelor's degree or Associate's degree in nursing; Unrestricted RN licensure required in Virginia
What days & hours will the person work in this position? List training hours, if different.
M-F 8-5
Type of Start
Individual starts
Is this an in-person, patient-facing role?
Yes
Onsite Requirements
Fully remote (never coming onsite)
PayRate: 0-37.16 $/hour