The RN Complex Case Manager will be responsible for leading the members of the Case Management team coordinating comprehensive health care services in a cost effective manner while assuring that quality is maintained for our senior members. A medical/social model will be used in the coordination of care based on establishment of utilization drivers, health coaching, and appropriate use of health plan benefits.
- Supports the vision and direction of the company and medical management department
- Supports sales and marketing in performing an initial telephone assessment of needs, coordination of home appointments, and assessing member needs during the pre-enrollment process.
- Using professional judgment and critical thinking skills will complete disease specific health appraisals/risk assessments
- Collaborates with attending physician, medical director, care partner, and team social worker to identify problems and develop a member specific plan of care
- Obtains plan benefits and established plan of care based on benefit design
- Channels health care services to contracted providers and seeks approval for coordination of out of network services when medically necessary
- Serves as a patient advocate
- Assists member and family in meeting their informational needs related to disease process, health plan, and opportunities for community support
- Develops and maintains in conjunction with the social worker local community resources by geographic area
- Participates in policy and procedure development, QI projects, and other job duties as necessary
High School Diploma required
Bachelor of Science in Nursing, Associate Degree in Nursing or Diploma Degree in Nursing preferred
Current RN California Nursing License
Case Management Certification preferred
Minimum 5 years acute clinical nursing experience
Minimum 3 years case management or disease management experience
- Medical terminology required , familiarity with ICD-9, CPT 4, managed care concepts desired.
- Familiar with managed care regulations and Medicare
- Have acute or ambulatory care experience in managing cardiac, pulmonary, renal and diabetes disease states
- Organizational design and direction and applying technology. Familiarity with governing entities (HCFA, DOC, NCQA) helpful
- Computer literate in Microsoft products, Crystal reporting, communication and virus protection software, PC maintenance, excellent data entry skills.
- Able to read and interpret information with excellent comprehension and retention
- Critical thinking skills, demonstrated by initiative, leadership and effective project management skills
- Self motivated, detail/results oriented, resourceful and able to work independently in pursuit of resolutions, identifying opportunities for organizational growth
- Strong quantitative, organization and auditing skills with high level of accuracy
- Excellent interpersonal skills and professional demeanor with clear and concise written and verbal communication
- Can flex and adapt schedule to attend various meetings, work overtime as needed.
- Knowledgeable of and able to maintain confidentiality in relation to HIPAA requirements
NAMM North America Medical Management - 4 months ago