Complex Case Manager (Temp)
NAMM North America Medical Management - Ontario, CA

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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 todisease 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:
RN with CA license

Case Management Certification preferred

Minimum 5 years acute clinical nursing experience

Minimum 3 years case management or disease management experience

Must be flexible, well organized, self starter and team player

Familiar with managed care regulations and Medicare

Have acute or ambulatory care experience in managing cardiac, pulmonary, renal and diabetes disease states

Ability to develop innovative approaches in delivering health care and social services to assist member in maintaining independence or slow disease progress

Possess excellent verbal and written communication skills

NAMM North America Medical Management - 5 months ago - save job - block
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