Case and Disease Manager RN

Company Overview

CSTS Customer Service and Technology Solutions LLC is a leading third-party administrator specializing in the healthcare sector. Our mission is to transform the healthcare experience by providing exceptional administrative services, including claims processing, customer enrollment, and compliance with federal regulations.

Summary: The practice of case management and disease management is a process that manages client wellness and autonomy through advocacy, communication, education, and the identification and facilitation of services. Case management and Disease Management are collaborative processes that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs. It uses communication and available resources to promote quality, cost-effective outcomes.

The Case Manager for IPA/MSO role and responsibilities span a culturally diverse population from neonatal to geriatric and may vary depending upon project assignment; however, regardless of payer or line of business, the nurse manager applies the same core practices of case management tailored to each member's unique disease, condition, and cultural values. The corporation throughout its multiple lines of business as an MSO, has various projects where case management services are needed that include, but is not limited to Medicare FFS, HMO, PFFS, Medicaid, Dual Eligible and QMBs, Medicare Advantage products with different coverage and benefit plans unique to the organization served. Additional projects may be assigned to nurse case managers to enhance and support specific quality projects as specified by the Manager.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Duties and Responsibilities:

Responsible for the daily operational duties across the IPA/MSO, including, but not limited to:

1. Knowledge of NCQA requirements

2. Health Plan Special Needs experience

3. Assess, plan, implement, coordinate, monitor and evaluate members in order to identify and follow those members who would most benefit by case management and disease management process specific to the population served.

4. Develop with the member actionable case management care plans based upon (1) identification of problems or barriers that interfere with the member's health and wellness, (2) develop and implement case management interventions specific to targeted barriers, (3) establish measurable goals and time frames for completion (4) provide measurable outcomes of case management interventions and (5) reassess and/or evaluate the case management plan of care at regular intervals including progress toward goals.

5. Provide specific documentation all contacts, mode of contact, successful and unsuccessful.

6. Provide telephonic visits, to gather data for various forms provided by payers including, but not limited to, health risk assessments, fall risk assessments, Medication Adherence, Medication possession (fills), Retail vs. Mail order, multiple ER visits, re admissions, High Risk Drugs, Patient Safety projects, CMS 5 Star preventative care, etc.

7. Provide extensive member teaching related to all projects (Complex Case, Short Term Case and Transitional Care and Disease Management) to enhance safety, adherence to medical and medication regimens, increase knowledge of disease process, maintain stability in chronic disease states, and arrange for services for those who are unable to afford the care required.

8. Provide member teaching during all contacts with members and monitoring of disease states and follow with written material per our service level agreements, as specified by the Health Plan.

9. Gather case data for the population served, including but not limited to, number identified for CM services, number enrolled, number followed at the facilities, case duration, number declined and long and short term goals met..

10. Frequent communication with physicians and physician offices as needed to facilitate access to needed care, arrange appointments, preventative care, education, report condition changes, perform medication reconciliation and management of chronic disease states as well as other case management interventions to avoid preventable admissions, re admissions and ER visits.

11. Provide high level review of medications, cost effectiveness and usage of generic medications to enhance medication adherence in the population.

12. Arrange for Patient Assistance Programs (PAPs) as needed.

13. Provide disease management education regarding the disease process and provide educational materials at intervals to support ongoing member education and stability.

14. Educate members on their individualized plan of care, including, but not limited to, their options, rights, and benefit plans (EOC).

15. Coordinate effectively with members and their families, the primary care physician, other case managers, and other care providers to develop, implement, and assess an individualized plan of care.

16. Participate in Interdisciplinary Care Team conferences.

17. Interface and refer complex cases to the corporate Medical Director.

18. Demonstrate consistent proficiency in member assessment, and case management services.

19. Demonstrate trustworthiness, honesty, and high personal standards in dealings with others at all times.

20. Show a high level of dedication to a commitment to excellence, working hard to deliver on commitments to others and ensure quality of care.

21. Pay careful attention to detail when reviewing member reports, laboratory results, and physician orders, filling out and submitting required documentation, and securing member records for various program resources.

22. Treat other people, including those of different backgrounds, beliefs, and gender, with fairness and respect.

23. Manage time to accomplish tasks efficiently and effectively.

24. Perform job duties in a reliable, responsible, and dependable manner (e.g., report to work and appointments consistently on time; complete tasks in a timely fashion).

25. Negotiate and advocate on behalf of the members to resolve problems and retain all available services and resources.

26. Establish and maintain cooperative working relationships with others, including members of the health care team, as well as their family members.

27. Exhibit maturity and self-control, even in situations involving conflict or stress.

28. Promptly communicate necessary and important information to members and their families, physicians, and other care providers.

29. Work effectively and efficiently under tight deadlines, high member volume, and multiple interruptions.

30. Remain sensitive to members' physical, emotional, cultural, linguistic and psycho social needs when interacting with them and managing their plan of care.

31. Display knowledge needed for the job, including relevant medical and case management procedures, policies and regulations )

32. Take the initiative to set goals, create plans, prioritize, and complete tasks, while requiring little or no supervision.

33. Ensure accuracy when performing tasks, including assessing members, developing and implementing plans for member care, and comparing members' progress with the plan of care.

34. Closely monitor the effectiveness of the current plan of care, identify any barriers that exist, and make appropriate adjustments as needed.

35. Accept feedback without becoming defensive and use the feedback to strengthen future performance.

36. Take responsibility for his/her actions and quality of work without blaming others or making excuses.

37. Other duties as assigned by the Manager.

Other Requirements: ICT meetings, IPA and MSO seminars and POD meetings including meetings with our customers, as well as educational events and seminars and to PCP offices in the State of Florida.

Education and Experience: RN with a state license in good standing with experience in multiple areas within the continuum of care. Case management experience in an IPA, home health, hospital, or health plan preferred. BSN, CCM, CRRN preferred.

Language Ability: Proficient in English, clear speaking ability, bilingual preferred.

Computer Skills: 40 WPM in typing, proficiency in MS Office including Outlook, Excel and Word. Experience with Case Management software including InterQual Care Enhance Review Manager Enterprise (CERME) preferred. High level of computer proficiency required.

If you are passionate about improving healthcare outcomes and have the skills to make a difference, we invite you to apply for the Case Manager position at CSTS today

Job Type: Full-time

Pay: $70, $80,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: Remote