Registered Nurse Senior
2 weeks ago
Case Managers perform a blended function of utilization management (UM) and case management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs. Determines develops and implements the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of: member inquiry, triage hub, chronic conditions, poly-pharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits.
Responsibilities:
- Researches and designs treatment /care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type.
- Implements discharge (DC) planning activities for medically complex cases.
- Determines appropriateness of referral for CM services.
- Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
- Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
- Manages member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity.
- Negotiates with employer groups when contractually required.
- Assessment: Assesses members health behaviors, cultural influences and clients belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers.
- Researches opportunities for improvement in assessment methodology and actively promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.
- Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits clients involvement.
- Planning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes. Adjusts plans or creates contingency plans as necessary.
- Assesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.
- Assists with precepting responsibilities for new hires and auditing efforts.
Minimum Experience Level:
- Generally requires moderate to extensive experience in nursing, health care or related field.
- Requires extensive experience in nursing, health care or related field. (5-7 years)
- 3+ yrs managed care experience preferred.
- Able to operate PC-based software programs including proficiency in Word and Excel.
Supervisory Responsibilities:
- QA and regular performance audits.
- Training and mentoring as
- backup to Lead as needed.
Compensation:
The pay rate range above is the base hourly pay range that Aditi Consulting reasonably expects to pay someone for this position (compensation may vary outside of this range depending on several factors, including but not limited to, a candidate's qualifications, skills, competencies, competencies, experience, location and end client requirements).
Benefits and Ancillaries:
Medical, dental, vision, PTO benefits and ancillaries may be available for eligible Aditi Consulting employees and vary based on the plan options selected by the employee.
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