Job Description
Role Description
- This position functions as a member of the interdisciplinary healthcare team in the provision of RN (Registered Nurse) Service Coordination Level 1 member care with the underlying objectives of enhancing the quality of clinical and financial outcomes and member satisfaction while managing the plan of care.
- Conducting telephonic or face-to-face holistic evaluations of Member's individual dynamic needs and preferences.
- Gathering relevant data and obtaining further information from Member/family.
- Identification, evaluation, coordination, and management of member's needs, including physical health, behavioral health, social services, and long-term services and supports.
- Provides education and support to Member/LAR on options of Consumer Directed, or Service-Related delivery models as applicable.
- Performs initial assessments and follow-up assessments and outreach calls within the time specified as part of contractual guidelines or per Member/family/provider request.
- Identifies members for high-risk complications and coordinates care with the member and the health care team.
- Manages members with chronic illnesses, co-morbidities, and/or disabilities to ensure cost-effective and efficient utilization of health benefits.
- Assesses, plans, and implements care strategies that are individualized for each member and directed toward the most appropriate, least restrictive level of care.
- Utilizes both company and community-based resources to establish a safe and effective case management plan for members.
- Collaborates with member, family, and healthcare providers to develop an individualized plan of care.
- Identifies and initiates referrals for social service programs, including financial, psychosocial, community, and state supportive services.
- Manages care plan throughout the continuum of care as a single point of contact.
- Communicates with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members.
- Advocates for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the healthcare team.
- Utilizes approved clinical criteria to assess and determine appropriate level of care for members.
- Documents all member assessments, care plan, and referrals provided.
- Participates in Interdisciplinary team meetings and Utilization Management rounds and provides information to assist with safe transitions of care.
- Understands insurance products, benefits, coverage limitations, insurance, and governmental regulations as it applies to the health plan.
- Monitors services being delivered to ensure timeliness, appropriateness, and satisfaction in meeting Member needs.
- Reports medically complex cases to appropriate roles as necessary for review and problem solving.
- Maintains status on face-to-face and telephonic visit requirements for assigned Members.
- Qualifications
- Knowledge of specific case management processes, and person-centered care practice.
- Excellent verbal and written communication skills.
- Analytical decision-making and judgment skills.
- Demonstrated ability to function as a clinical care team leader.
- Knowledgeable of all clinical resources available to patients both inpatient and outpatient.
- Data Entry and Word Processing Skills.
- Requirements
- Current unrestricted RN license in Texas, Graduate of an accredited school of nursing.
- 2+ years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities within a community health, clinical, hospital, acute care, direct care, or case management setting.
- 2+ years of experience working with MS Word, Excel, and Outlook.
- Bilingual - Spanish.
- Ability to travel in assigned region to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, etc.
- Reliable transportation with valid driver’s license with good driving record.
- Preferred Qualifications
- Bachelor’s Degree.
- CCM/RUG/PDPM Certified.
- 2+ years of experience working with Medicaid Waiver populations.
- 2+ years of experience working within the community health setting in a health care role.
- STAR+PLUS Service Coordination Experience.
- Experience with electronic charting.
- Experience with arranging community resources.
- Field-based work experience.
- Behavioral Health Experience.
- Proven background in managing populations with complex medical or behavioral needs.
- Benefits
- Comprehensive benefits package.
- Incentive and recognition programs.
- Equity stock purchase.
- 401k contribution (all benefits are subject to eligibility requirements).
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