Case Management RN

Utilize a collaborative process to assess, plan, implement, monitor, and evaluate options and services required to meet the member’s healthcare needs. Through communication, the case manager will identify available resources to promote quality, cost effective outcomes. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: MANAGER, POPULATION HEALTH
• Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with:
  
  Benefits Administration, Medical Director, Underwriting, Group leaders, Delegated Vendors, Legal Department and other employees as needed, physicians/staff, hospital administrators/staff, providers, caregivers, subscribers, community resources

• Bachelor's in nursing, business administration, healthcare or a related field is required
• RN license can be used in lieu of Bachelor's degree
• LPN license to practice in Louisiana as well as two years of related experience can be used in lieu of a Bachelor's degree
• Four years of related experience can be used in lieu of a Bachelor’s degree.

• 2 years Direct patient care/clinical experience. required

• Ability to research and analyze contracts/cases and make appropriate quality and cost effective decisions.
• Strong communication skills, including the ability to effectively explain/present claims information and procedures to persons with varied levels of insurance/benefits understanding.
• Excellent organizational and analytical skills.
• Ability to make decisions, prioritize, find solutions, and work independently.
• Working knowledge of related software and office equipment.

• Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure RN licensed to practice in Louisiana
  required
• Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure RN license to practice in states other than Louisiana is. Must attain RN license to practice in states other than Louisiana within 12 months after date of hire. preferred
• Case Management Certification or attained within 48 months after date of hire. preferred

• Assess member’s status by collecting in-depth information in culturally competent and confidential manner, about the member’s situation and functioning to identify individual needs in order to develop and implement a comprehensive case management plan that will address needs for moderated to high risk cases.
• Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators. The case manager will act as an advocate for the member/family, maintaining privacy, confidentiality and safety, building relationships with all relevant parties, supporting informed decision making and facilitating access to necessary and appropriate healthcare services across the continuum of care.
• Implement specific interventions and evaluate effectiveness that will lead to accomplishing the goals established in the plan. Experienced in behavioral interviewing techniques.
• Coordinate by collaborating with the member/family, providers, third party payors, employers and community resources in order to organize, integrate, and modify the resources necessary to accomplish the goals. Assist with return to work, vocational development, and life care planning.
• Responsible for meeting annual targets for program performance as mutually agreed to by management team to maximize program value. Participates in quality improvement projects and data collection to determine the effectiveness of the case management program.
• Participates on project workgroups.
• Familiar with guidelines and requirements for authorizations of services related to coordination of care for complex cases. Proficient in care management authorization processes, including usage of standard clinical guidelines such as milliman care guidelines, as part of management of complex case management cases.
• Conduct case conferences with member, provider, and facilities as appropriate.
• May provide guidance to less experienced nurses.The physical demands described here are representative of those that must be met by an employee to successfully perform the accountabilities (essential functions) of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

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