RN Case Manager

Primary Purpose:

To provide support and facilitate care of members who require case management.  To work collaboratively with Health Plan and Hospital Case Management Departments in the facilitation of services.   To collaborate with the treating physician and IPA Medical Director in the review and decision-making process regarding the facilitation of appropriate health care and service requests.  Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates individual’s health needs through communication and available resources to promote quality, cost effective outcomes.

Principal Duties and Responsibilities (* = essential functions):

·        To utilize the Case Management functions:  assessor; planner; facilitator; advocate.*

·        To facilitate services at the appropriate Health Plan center of excellence. *

·        To utilize the most cost effective case rates and contracts. *

·        To review and process clinical information in accordance with regulatory mandates to facilitate patient healthcare and services, across the continuum of care.*

·        To perform catastrophic case management as appropriate to the patient’s medical condition and healthcare needs utilizing the standards of practice for Case Management.

·        To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information.*

·        To prepare and participate in health plan audits onsite as required.

·        To actively participate in Utilization Management Committees in regard to Case Presentations and problem solving.

·        To participate in the development of Case Management Policies and Procedures.

·        To actively participate in the discharge planning process.*

·        To perform other duties as assigned.

Job Specifications (KSAs):Requires extensive and specialized knowledge of utilization and case management processes as is generally acquired by 2-3 years or greater of experience as a case manager in a Managed Care Environment, successful completion of a nursing program.Requires prior Case Management experience preferably with catastrophic cases.Requires an active RN or LVN license in the state of employment.Requires clinical expertise as is generally acquired by 3 to 5 years of acute nursing practice.Requires excellent written and verbal communication skills.Requires computer experience, particularly Microsoft Word, Excel and the ability to learn new medical management applications quickly.Requires problem solving and critical thinking skills.Requires professional demeanor and the ability to contribute to a positive work environment.Requires knowledge of regulatory standards such as Medicare, TitleXXII.*Requires extensive knowledge of health plan guidelines.

 

Position Performance Criteria:

1.      Demonstrates proficiency in UM and Case Management including but not limited to:Catastrophic Case ManagementTransplant ManagementReferral reviewOut of network managementDenial letter processConcurrent/inpatient review and bed-day management.

2.      Demonstrates the effective practice of Case Management Standards of Care including: AssessmentCase Identification and SelectionPlanningMonitoringEvaluating Outcomes

3.      Sets appropriate priorities to meet departmental goals and objectives including but not limited to:Demonstrates ability to efficiently manage case load.Demonstrates ability to set appropriate prioritiesConsistently renders prudent and sound decisionsManages multiple tasks while meeting required timeframesAdheres to departmental policies and procedures

4.      Demonstrates knowledge of Health Plan guidelines.

5.      Demonstrates knowledge of federal, state, NCQA, and health plan regulatory requirements and approved criteria guidelines.Ensures consistency in the application of the utilization process.Maintains knowledge of new legislation and disseminates information to providers and co-workers.

4.      Demonstrates ability to give concise, articulate and accurate case presentations to Medical Director, UMC, etc including problem solving.

5.      Demonstrates cost savings.

6.      Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to:

·        Professional appearance and demeanor

·        Meets departmental attendance needs on site

·        Participates verbally in group activities, i.e. staff meetings, etc.

·        Demonstrates respect to co-workers and customers.

·        Works collaboratively with other departments to identify and resolve issues.