Care Management Nurse

3 weeks ago

Boise, United States Cambia Health Solutions, Inc Full time

Care Management Nurse - Hybrid

ID - Independent Doctors of Idaho (IDID)



Primary Job Purpose

The Care Management Nurse provides clinical care management (such as case management, disease management, and/or care coordination) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member's care to assess, plan, implement, coordinate, monitor and evaluate care as needed.



General Functions and Outcomes

  • Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.

  • Assessment: collection of in-depth information about a member's situation and functioning to identify individual needs.

  • Planning: identification of specific objectives, goals, and actions designed to meet the member's needs as identified in the assessment.

  • Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan.

  • Coordination: organization, securing, integrating and modifying resources.

  • Monitoring: gathering sufficient information to determine the plan's effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.

  • Consults with physician advisors to ensure clinically appropriate determinations.

  • Serves as a resource to internal and external customers.

  • Collaborates with other departments to resolve claims, quality of care, member or provider issues.

  • Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.

  • Responds in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.

  • Provides consistent and accurate documentation.

  • Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.



Minimum Requirements

  • Knowledge of health insurance industry trends, technology and contractual arrangements.

  • General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.

  • Strong oral, written and interpersonal communication and customer service skills.

  • Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.

  • Strong organization and time management skills with the ability to manage workload independently.

  • Ability to think critically and make decision within individual role and responsibility.

Normally to be proficient in the competencies listed above

Care Management Nurse would have a/an Associate or Bachelor's Degree in Nursing or related field and 3 years of case management, utilization management, disease management, or behavioral health case management experience or equivalent combination of education and experience.



Required Licenses, Certifications, Registration, Etc.

Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care

Must have at least one of the following: Certification as a case manager from the URAC-approved list of certifications; or Bachelor's degree (or higher) in a health or human services-related field (psychiatric RN or Master's degree in Behavioral Health preferred for behavioral health care management); or Registered nurse (RN) license (must have a current unrestricted RN license for medical care management)



Work Environment

Duties performed at home and in Independent Doctors of Idaho - IDID


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