Lead Nurse Care Coordinator
2 weeks ago
Position Overview: The Lead Nurse Care Coordinator plays a pivotal role in managing the healthcare journey of members facing complex and chronic health challenges. This position involves a comprehensive approach to care management, ensuring that members receive the necessary services tailored to their specific health requirements.
Key Responsibilities:
- Conduct thorough assessments to determine individual needs and create a targeted care management strategy aimed at achieving defined health objectives.
- Execute the care plan by facilitating necessary authorizations and referrals within the established benefits framework or through alternative arrangements.
- Coordinate both internal and external resources to effectively address identified health needs.
- Continuously monitor and assess the success of the care management plan, making adjustments as required.
- Collaborate with Medical Directors and Physician Advisors to formulate care management treatment strategies.
- Engage in negotiations regarding reimbursement rates, when applicable.
- Support problem resolution with healthcare providers, claims, or service-related issues.
- Contribute to the development of utilization and care management policies, lead meetings, and present cases during Grand Rounds or Care Conferences, while participating in interdepartmental workgroups.
- May necessitate the acquisition of specialized knowledge regarding specific disease processes or traumatic injuries, serving as a mentor for new care management personnel.
- Participate in audit processes and assist management in overseeing daily operations, including workflow prioritization, providing constructive feedback, and formulating corrective action plans as directed.
- Act as the primary contact for conflict resolution.
- Develop training resources, conduct quality audits, perform process evaluations, and oversee system enhancements.
Qualifications:
- A Bachelor's degree in a health-related discipline and a minimum of five years of clinical experience, or an equivalent combination of education and experience.
- A current, unrestricted RN license in the relevant state(s) is mandatory.
- Certification as a Case Manager is highly desirable.
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