Case Manager - RN

Job Summary:

The Case Manager – RN collaborates with members of an inter-disciplinary care team (ICT) to meet the needs of the individual and the population and identifies problems or opportunities that would benefit from care coordination.

Essential Functions:

• Engage the member and complete a health and psychosocial assessment, taking into account the cultural and linguistic needs of each member
• Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member
• Engage with the member to establish an effective, professional relationship via telephonic or electronic communication
• Develop an individualized care plan (ICP) in collaboration with the ICT, based on member’s needs and preferences
• Identify and manage barriers to achievement of care plan goals
• Identify and implement effective interventions based on clinical standards and best practices
• Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management
• Facilitate coordination, communication and collaboration with the member the ICT in order to achieve goals and maximize positive member outcomes
• Educate the member/caregivers about treatment options, community resources, insurance benefits, etc. so that timely and informed decisions can be made
• Employ ongoing assessment and documentation to evaluate the member’s response to and progress on the ICP
• Evaluate member satisfaction through open communication and monitoring of concerns or issues
• Collaborate with facility based case managers and providers to plan for post-discharge care needs or facilitate transition to an appropriate level of care in a timely and cost-effective manner
• Coordinate with community-based case managers and other service providers to ensure coordination and avoid duplication of services
• Appropriately terminate care coordination services based upon established case closure guidelines for members not enrolled in the MyCare or DSNP plan
• Provide clinical oversight and direction to unlicensed team members as appropriate
• Document care coordination activities and member response in a timely manner according to standards of practice and CareSource policies regarding professional documentation
• Look for ways to improve the process to make the members experience with CareSource easier and shares with leadership to make it a standard, repeatable process
• Perform any other job duties as requested

Additional Essential Functions for MyCare or DSNP Plan Case Managers:

• Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management
• Verify eligibility, previous enrollment history, demographics and current health status of each member
• Completes psychosocial and behavioral assessments by gathering information from the member, family, provider and other stakeholders
• Oversee (point of contact) timely psychosocial and behavioral assessments and the care planning and execution of meeting member needs
• Participate in meetings with providers to inform them of Care Management services and benefits available to members
• Assists with ICDS model of care orientation and training of both facility and community providers

Education and Experience:

• Nursing degree from an accredited nursing program is required
• Bachelors of Science in Nursing is preferred
• Licensure as a Registered Nurse is required
• A minimum of three (3) years of experience in nursing (i.e. discharge planning, case management, care coordination, and/or home/community health management experience) is required
• Three (3) years or more Medicaid and/or Medicare managed care experience is preferred

Competencies, Knowledge and Skills:

• Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel
• Ability to communicate effectively with a diverse group of individuals
• Ability to multi-task and work independently within a team environment
• Knowledge of local, state & federal healthcare laws and regulations & all company policies regarding case management practices
• Adhere to code of ethics that aligns with professional practice
• Knowledge of and adherence to Case Management Society of America (CMSA) standards for case management practice
• Strong advocate for members at all levels of care
• Strong understanding and respect of all cultures and demographic diversity
• Ability to interpret and implement current research findings
• Awareness of community & state support resources
• Critical listening and thinking skills
• Decision making and problem solving skills
• Strong organizational and time management skills

Licensure and Certification:

• Current unrestricted clinical license as a Registered Nurse (RN) is required; RN licensure may be required in multiple states as applicable based on State requirement of the work assigned
• Case Management Certification is highly preferred
• BH experience strongly preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer
• Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members