RN Case Management Specialist
HealthNow New York Inc. - Buffalo, NY

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Position Summary:
This position assists in ensuring that quality, cost-effective care is delivered to members of all product lines of HealthNow NY Inc. The incumbent will assist in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits. This position will also assess, plan, coordinate, implement, monitor, and/or evaluate the options and services to meet an individual's health needs.

Primary Job Duties:
Acting as an advocate and liaison to meet a member's individual health care needs by assessing, planning, implementing, coordinating, monitoring and evaluating options and services. This is accomplished by using communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits. (30%)

Exhibits and applies clinical understanding (in related discipline) of the medical diagnosis (es), case management processes, and psycho-social needs of members and their support system toward the development of an appropriate treatment plan in conjunction with the member's physician(s) and other pertinent allied health professionals (30%)

Works collaboratively and communicates clearly and professionally with physicians, providers, co-workers and other members of the health care team in order to carry out the established plan of care. (10%)

Demonstrates a thorough understanding of and applies the principles/standards of URAC and NCQA, Medical Services initiatives, and Strategic Business Unit goals. (10%)

Identifies areas for potential cost savings, quality improvement and workflow efficiencies. (10%)

Ability to work both as a team member and independently, demonstrating sound problem solving techniques. (10%)

For Behavioral Health positions: Facilitates integration of behavioral health case management into the member's overall medical treatment plan. Educates member about mental or physical illness, abuse, medication, or available community resources.

For Inpatient Clinicians: Facilitates integration of inpatient care coordination and transition of care into the member's overall medical treatment plan; Supports and educates members and families regarding inpatient processes as needed; Communicates and facilitates post acute member needs.

Required Skills

Primary Skills/Knowledge:
Excellent time management skills

Excellent verbal and written communication skills

Ability to work effectively with minor supervision

Must be able to work in a fast-paced environment with daily work processing deadlines

High energy level and ability to project enthusiasm

Persuasive communication style

Polished, professional image and reputation

Demonstrated customer service orientation

Demonstrated personal accountability

Knowledge of MS Word, Excel, Access, and Internet preferred

Knowledge of case management, managed care, health insurance industry, and the provider community a plus

Required Experience

Preferred Education:
Bachelors Degree (Nursing)

Preferred Experience:
CCM designation required within 3 years of accepting position. 3 years clinical experience, 1 year of which must be in a hospital setting. Multi-state RN licensure preferred. Associates degree considered with RN and equivalent experience.

Alternate Education:
No degree specified (N/A)

Alternate Experience:
For Behavioral Health positions: requires Bachelors of Nursing(BSN), Masters of Social Work(MSW), Licensed Clinical Social Worker(LCSW), Licensed Mental Health Counselor(LMHC), or Licensed Marriage and Family Therapist(LMFT). Recent experience in assessing and managing behavioral health and/or medical diagnoses. Multi state RN preferred.

Alternate Education:
No degree specified (N/A)

Alternate Experience:
For Inpatient Clinicians: Inpatient case management or discharge planning experience desirable.

Working Conditions:
Must be able to work in an office environment

Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks

Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)

PPD Skin Test may be required by healthcare facility for onsite facility work

Required Licenses/Certifications:
Registered Nurse

Certified Case Manager

HealthNow New York Inc. - 15 months ago - save job - block
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