RN Case Manager

The RN Case Manager is primarily responsible for the daily management and support of the Case Management strategies for care coordination for a group of members who are associated with a Medicare Advantage plan. Visit (in person and/or telephonic) patients to ensure proper nursing care. Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims. Consult and coordinate with health care team members to assess, plan, implement and evaluate patient care plans.

This position requires an individual who is a self-starter and team player, has the ability to manage multiple priorities, work with minimal supervision on assigned projects and activities, and demonstrates excellent communication and presentation skills. This individual must be able to adapt quickly to change and be able to collaborate with multiple teams

JOB SUMMARY:

The Registered Nurse Case Manager is responsible for providing daily management and support regarding case management strategies for care coordination for patients associated with a Medicare Advantage plan.

ESSENTIAL JOB DUTIES:

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.
• Manage assigned patient caseload
• Complete health risk assessments for designated members
• Initiate, reassess and revise plans of care in collaboration with the health care team as appropriate
• Evaluate, coordinate, and plan patient care in collaboration with the interdisciplinary health team
• Provide education to the patient/family and facility staff in accordance with identified needs utilizing available teaching resources as needed
• Coordinate outpatient discharge planning in accordance with patient needs, clinical circumstances and benefit coverage
• Participate in all Managed Care related audits; generate, maintain and track reports and documents to support Care Coordination program
• Perform improvement projects involving development of monitoring/collection tools, review of medical records, data entry, analysis, and preparation of audit findings and reports
• Participate in patient care conferences, committee meetings, staff development and educational programs to maintain professional competency
• Apply medical management criteria correctly
• Research clinical questions from employers, members and payors as required; educate members on health access options
• Respond, manage, and resolve day-to-day issues presented in care coordination; communicate effectively with the facility
• Rounding in patient care delivery areas per market needs.
• Other duties as assigned

JOB REQUIREMENTS:

• Successful completion of required training
• Maintain established work schedule
• Handle multiple priorities effectively
• Independent discretion/decision making
• Reliable transportation
• Current automobile insurance according to company policy
Required Computer Software/Equipment used:
• Standard office equipment
• Microsoft Suite applications
• Desktop, laptop and/or iPad
• Standard medical equipment

REQUIRED QUALIFICATIONS:

Education:
o Graduate from an accredited Registered Nursing Program
o Bachelor’s degree preferred
Experience:
o Two (2) years’ experience in clinical nursing or rehabilitation for the geriatric population
o Two (2) years’ experience in managed care 3-5 years’ experience performing case management within a managed care environment
License/Certification(s):
o Current state Registered Nursing License
o Current and valid driver’s license
o Current motor vehicle insurance

COMPANY COMPETENCIES:

• Respect – We treat people as they want to be treated, showing regard for their rights and privacy
• Integrity – We emphasize honesty, fairness, and doing the right thing even when no one is watching
• Teamwork – We work collaboratively to improve processes, resolve problems and reward results
• Excellence – We hold ourselves to the highest standards, aspiring to zero defects in every task
• Compassion – We respond to those who need help with sensitivity and a positive attitude
• Professionalism – We perform our duties with skill, good judgement and politeness

JOB COMPETENCIES:

1. Analytical Thinking: Able to gather and analyze data and reach appropriate conclusion; solves problems in a timely manner. Use logic and reasoning to identify changes in patients’ conditions to determine the correct plan of action.
2. Customer and Personal Service: Possess good interpersonal skills while dealing with emotional or difficult situations; respond promptly to customer’s needs. Knowledge of principles and processes for providing personal services, including needs assessment; meet quality standards.
3. Accountability: Accept responsibility for own decisions, actions and results; able to maintain dependable behavior in times of crisis or complexity.
4. Attendance: Consistently at work and on time; ensure work responsibilities are covered; return from lunch and breaks appropriately; arrive at meetings on time; notifies supervisor of pending absences.
5. Communication: Speak and write clearly and persuasively; listen and receive clarification.
6. Ethical Behavior: Uphold organizational values and abide by state and federal regulations; maintain confidentiality of HIPAA information; treat others with respect.
7. Initiative: Seek increased responsibility; set self-improvement goals related to the organization’s objectives.
8. Job and Industry Knowledge: Demonstrate knowledge of the position and industry; seek additional information.
9. Productivity and Quality of Work: Maintain high level of performance while demonstrating commitment to accuracy and thoroughness.
10. Teamwork: Display ease working with others; contribute ideas and skills to team; put success of team above own interests. Communicate with co-workers at all levels to adequately meet the needs of patients.

SCOPE AND LEVEL OF WORK:

• Complexity: Duties assigned are not generally complex. Work assignment is performed within an established framework under general instructions but requires simultaneous coordination of assigned functions or projects in various stages of completion.
• Decision Making: Exercises judgment and discretion at all times.
• Communications: Contacts with the public or employees where explanatory or interpretive information is exchanged,
defended, and gathered and discretion and judgment are required within the parameters of the job function.
• Supervision Received: Performs work with supervisory oversight. Under general supervision, receives assignments and is
expected to carry them through to completion with substantial independence. Work is reviewed for adherence to
instructions, accuracy, completeness, and conformance to standard practice or precedent. Recurring work clearly covered
by guidelines may or may not be reviewed.

SUPERVISORY RESPONSIBILITES:

• Does not have supervisory responsibilities
• Provides training and education to facility staff
• Occasionally needs manager’s direction due to extraordinary circumstances

WORKING CONDITIONS:

• Audio-Visual: Good
• Hearing: Good
• Ability to lift to 40 pounds
• Subject to standing, walking, sitting, bending, reaching, kneeling, pushing and pulling• Work is typically performed in a standard office environment; well-lit; comfortable temperature-controlled
• Above-average conversational noise is frequent
• Position may require flexible hours, unscheduled overtime or occasional week-end work
• Travel required
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SAFETY EXPECTATIONS:

• Work safely and follow safety rules
• Report unsafe working conditions and behaviors
• Take reasonable and prudent actions to prevent others from engaging in unsafe practices

EQUAL OPPORTUNITY EMPLOYER

This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.