Nurse Case Manager
AmeriHealth Mercy Family of Companies - Philadelphia, PA

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The primary purpose of the job is to :
  • Identifies screens/assesses, stratifies, plans and implements case management interventions in accordance with disease management program clinical guidelines. Collaborates with the member and their treating physicians, assists in the identification and implementation of a specific plan of care, intervention and education of members. Monitors member’s ongoing progress and outcomes; provides ongoing evaluation of program effectiveness. Functions as liaison between member, treating physician, pharmacy provider, treatment center, and insurance carrier to ensure services provided are clinically appropriate, cost effective and least restrictive. Arranges for services and appointments as needed, and monitors compliance. Maintains a respect for a member’s cultural differences while ensuring treatment plans are implemented. Collaborates with the member, member’s family and members of the treatment team to ensure that the member’s treatment plan is well coordinated and managed. Develops an assessment and plan of care identifying health history, psychosocial assessment, medications and treatments, support systems, functional abilities and limitations, history of chronic and acute illness, short term and long term goals, equipment needs, and services requirements. Reviews plan of care with the member and/or family member and members of treatment team as appropriate including insurance provider pharmacist reviewer.
  • Works with Pharmacy Data Analyst to identify, stratify, and assess members for inclusion in the Bleeding Disorder program at a minimum on an annual basis.
  • Conducts/coordinates off site and home visits as requested in department guidelines and additional visits as necessary when deemed appropriate.
  • Provides proactive discharge planning by collaborating with pharmacy vendors, primary care physicians and/or office staff, specialty physicians and/or office staff, hospital discharge planners, social workers, and home visit nursing staff.

Position Requirements:

-Three to Five Years Nursing experience preferably in an ER, MICU or Urgent Care clinical environment

-Unrestricted and active PA RN license

Additional Preferred Assets:

-Certified Case Manager (CCM)

-Previous experience in specific disease management

-Previous case management experience

-Working knowledge of blood disorders

-Previous experience in specific disease management programs preferred

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