RN Case Manager

Overview Responsible for case management activities for Health Alliance Plan (HAP) Special Needs Plan (SNP) members using a multi-disciplinary, patient-centered approach. Provides bio/psycho/social assessments, develops an individualized care plan, implements case management interventions, facilitates an interdisciplinary care team, coordinates care, monitors outcomes and evaluates the delivery of quality, cost effective health care services across the continuum of care. Oversees the day-to-day operations of member-centered comprehensive care coordination for members enrolled in special needs plan programs, while ensuring adherence to all regulatory requirements. Principle Duties and Responsibilities Facilitate access of healthcare services for SNP eligible members and identify plans for strategies to reduce avoidable utilization and encourage appropriate resource use. Works with physicians and other health care providers to adjust plans of care as required Provide liaison services to SNP members and providers. Represents HAP in the community to peers, physicians, and providers as a member advocate for the HAP SNP population Conduct assessments of members needs including current health conditions, preventive screenings, medical service utilization, cognitive/functional status, social determinant of health concerns (including food insecurity, transportation and housing) and behavioral health concerns including depression and substance use screening Collaborate with external resources/agencies and post-acute care health teams to optimize the member outcomes and improve the care experience when transitioning to the next level of care or home Familiarity with the Special Needs Plan Model of Care (MOC) and ensuring compliance Attend and actively participate in the SNP member advisory committee, offering oversight and resolution as necessary based on feedback received Develop, implement, monitor, and modify a plan of care through an interdisciplinary and collaborative team process, in conjunction with the member, the caregivers and the healthcare team Maintain a level of competency and knowledge related to case management, disease processes and acute illnesses to assist with care coordination Advocate for the member/family/caregiver throughout episodes of care Maintain availability to member/family/caregiver as a resource to facilitate communication among the multidisciplinary team and to monitor services rendered. Remains involved throughout the members enrollment in the SNP plan Develop and maintain relationships with internal and external resources to ensure member needs are met. Identify the need for and coordinate mental health/substance abuse interventions within HAP (or designee) Use independent, clinical judgment and discretion to address, resolve, and process problems impeding the diagnostic or treatment process. Proactively identify and resolve delays and obstacles Facilitate referrals for additional medical and ancillary services, including home healthcare, infusion therapy, palliative care, hospice, inpatient extended care facilities, and medical equipment and supplies, as needed Participate in the development of cost savings opportunities through the identification of quality management, case management, and multi-disciplinary processes Refer cases to Physician Advisors and/or Plan Medical Directors when appropriate, where quality issues are identified Coordinate and assist in the development of innovative alternative care delivery mechanisms to meet special needs of members Maintain electronic medical records including professional, clinical documentation to ensure continuity of care and compliance to regulatory requirements (e.g., HIPAA, SNP Model of Care, CMS guidelines) Other duties as assigned Education/Experience Required Previous experience with special needs plan population preferred Bachelors degree in nursing or health services related field preferred Minimum of three (3) years of relevant clinical experience in the medical inpatient or ambulatory setting or specialty experience required Experience in medical case management, discharge planning, home health care, rehabilitative medicine, community health, managed care/health insurance preferred Certifications/Licensures Required Current Michigan Registered Nursing Licensure. Must possess a valid driver's license and maintain a driving record that meets the criteria specified through the Henry Ford Healths Corporate Insurance Program. #J-18808-Ljbffr