Clinical - Care Manager II (RN)

3 weeks ago

McAllen, United States Axelon Full time

Location: This is a Member facing position, Texas

Hidalgo SDA

Brownsville and surrounding cities/towns.

Travel to member homes 3 days a week to complete assessments. Distance varies on where member lives.

SHIFT: 8am

5pm

Occasional overtime

Job Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.

Education/Experience: Graduate from an Accredited School of Nursing. Bachelor s degree in Nursing preferred. 2+ years of clinical nursing experience in a clinical, acute care, or community setting and 1+ years of case management experience in a managed care setting. Knowledge of utilization management principles and healthcare managed care. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs.

Licenses/Certifications: Current state s RN license.

Texas Requirements:

Education/Experience: Graduate from an Accredited School of Nursing. Bachelor s degree in Nursing preferred. 2+ years of clinical nursing or case management experience in a clinical, acute care, managed care or community setting. 2+ years experience working with people with disabilities and vulnerable populations who have chronic or complex conditions in a managed care environment. Experience with medical decision support tools (i.e. Interqual, NCCN) and government sponsored managed care programs. Other state specific requirements may apply.

Job Duties:

" Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options

" Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes

" Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients

" Provide patient and provider education

" Facilitate member access to community based services

" Monitor referrals made to community based organizations, medical care and other services to support the members

overall care management plan

" Actively participate in integrated team care management rounds

" Identify related risk management quality concerns and report these scenarios to the appropriate resources.

" Case load will reflect heavier weighting of complex cases than Care Manager I, commensurate with experience

" Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems

" Direct care to participating network providers

" Perform duties independently, demonstrating advanced understanding of complex care management principles.

" Participate in case management committees and work on special projects related to case management as needed

Walk me through the day-to-day responsibilities of this the role and a description of the project:

Completing assessments

Completing biannual

Telephonic outreaches

Care coordination

Follow up on request from members/LAR

Complete any assigned trainings.

Completing all required documentation

Submitting authorizations

Travel (home visit to complete assessments)

Maintaining at least 92% audit score

Providing member/LAR education

Productivity reports

Follow up with HEDIS measures

Assisting members/LARs with finding doctors, therapy agency, PCS agency, DME and etc...

These are most of the responsibilities listed above.

Describe the performance expectations/metrics for this individual and their team:

To complete work (listed above) with in turnaround time, as listed in work process and contract.

Maintain at least 92% on audits.

What previous job titles or background work well in this role?

They will have to have the RN license and pediatrics is a plus.

Internal/External Groups with which the Candidate will interface:

Required Skills/Experience:

Preferred Skills/ Experience:

1. RN license 1.

2. Pediatrics 2.

3.

3.

Education Requirement:

Education Preferred:

Software Skills Required: Outlook, excel, word, Microsoft teams

Required Certifications: RN Required Testing:

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