CMRN
NAMM North America Medical Management - Overland Park, KS

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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.

Responsibilities:
  • 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

Qualifications:

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 - 19 months ago - save job
About this company
North American Medical Management, California, Inc. (NAMM) develops and manages provider networks, offering a full range of services to...