Job Details
This is a remote 6 month renewable contract with benefits with an insurance company
must have active NC license or company license
The Case Manager coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resource outcomes.
Job Description
Serve as a team member on a multidisciplinary Health Care Coordination team that monitors utilization patterns; identifies and facilitates appropriate health care service delivery for selected members, providers, procedures, and/or diagnoses; and improves the quality and cost efficiency of care and service.
Perform a comprehensive assessment of the member s health status, educational, and level of support needs. The assessment includes condition specific issues, clinical history, medications, activities of daily living, mental health status, cognitive functioning, life planning activities, cultural and linguistic needs, caregiver support and resources.
Develop a member centric care plan which includes long and short term goals, a self management plan tailored to member s needs, and identification of barriers to meeting goals or compliance to plan of care.
Perform ongoing monitoring and management of member including: scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation to MD, MSW, HLB, etc; assessment of progress towards goals, modification of plan/goals as needed, nurse contact at least every 30 days, complete documentation of calls and faxes with phone and fax numbers
Evaluate and facilitate care provided to members as they move through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care). Review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options.
Identify high risk, high cost, or high utilization cases. Encourage pro-active intervention to limit expense and encourage positive outcomes.
Maintain awareness of community resources and funding. Utilize resources and funding sources in the development of the case management plan.
May negotiate and secure contractual arrangements for provision of non-contracting providers.
Collaborate with primary care physician, On-Site Medical Care Coordinator, Discharge Services, Medical Director, Episodic Care Managers, the member, family members and other members of the health care team to develop and/or coordinate plans of treatment and appropriate discharge plans. This includes knowledge of disease process, and understanding of family dynamics, as they relate to the discharge planning/case management process.
Document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome. Complete all correspondence related to case management. Obtain consents as indicated. Analyze and report case management activity according to department policy.
Authorize appropriate services as defined by the department. Consult the medical director as appropriate. Refer cases that do not meet criteria to the Medical Director. May Issue denials according to department protocols. Document outcome of reviews. Negotiate and secure contractual arrangements for provision of non-contracting providers. Ensure medical necessity reviews and determinations meet all requirements imposed by regulatory agencies such as NCDOI, NCQA, Federal, etc. FEP CM s do not authorize acute rehabilitation inpatient care. This is the function of the ECM staff. FEP CM s collaborate with ECM s as appropriate, but are not responsible for the actual process.
Hiring Preferences
The incumbent must possess medical management/clinical decision-making skills and sound skills in assessing, planning and managing member care
Advanced assessment and teaching skills.
Problem solving skills.
Familiarity with legal terminology and liability issues and ability to handle ethical or risk management issues.
Utilization and Quality Management/Outcomes experience preferred.
Previous work experience with a managed care organization or provider is also preferred.
Prior experience in case management, home health, discharge planning, or Concurrent review.
Prior experience in a variety of health care settings is preferred
Experience with managing and coordinating care for patients who have multiple co-morbidities is preferred.
Excellent communication and interpersonal skills with all levels of internal and external customers necessary.
Individual must be self-motivated/self-directed.
Must possess the abilities to work independently, demonstrate effective time management skills, and to prioritize effectively.
The ability to deal effectively with change within the unstructured nature of case management and remain focused.
Demonstrates creativity, critical thinking, counseling, interviewing, negotiating, and research skills.
Hiring Requirements
RN Diploma, RN Associate s degree or Bachelor s of Science in Nursing (BSN) degree. Minimum of 3 years full time direct clinical experience in an acute medical or acute surgical setting.
Proficiency with a Microsoft Windows operating system
Must have valid license to practice nursing within the US and have started application for NC nursing license.