Nurse Case Manager

Description

Responsibilities

·        Provide comprehensive telephonic case management to targeted population who are identified with chronic diseases, as well as medically complex members referred for outreach. Develop a tailored plan of care that supports the needs of the members, influences adherence to treatment, assist with discharge planning as needed and care coordination to ensure optimal outcomes 

·        Apply nationally recognized clinical evidence-based guidelines and best practices approach to identify and address gaps in care

·        Communicate effectively with members, physicians, and providers; facilitate, advocate, and educate on the disease process; be a liaison and provide referrals to other departments and programs as needed

·        Use of information technology; navigate within care management application and document management systems and maintain accurate documentation of case management assessment, planning, goals and interventions.

·        Act as a Subject Matter Expert based on particular disease management areas of expertise: facilitate ongoing staff training, provide information regarding medications updates and continued education

·        Interpret reports, understand trends and target specific high risk population, provide recommendations, generate outcomes.

·        Promote active members involvement regarding their health care management and ability in  navigating health care delivery systems in order to preserve benefit resources

·        Authorize vendor services using clinically proven criteria to make consistent care decisions

·        Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services

·        Responsible for abiding by and supporting the care management programs in order to ensure quality and efficient clinical operations

·        Use industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach

·        Participation in Fund wide clinical events and Health Fairs

·        Perform additional duties and projects as assigned by management

Qualifications

·        Valid New York State Registered Nurse (RN) required

·        Minimum three (3) years Medical/Surgical experience plus a minimum of two (2) years Case Management/Disease Management experience required

·        BSN and Certification in Case Management a plus

·        Knowledge of HEDIS, NCQA, QARR a plus

·        Strong knowledge of Clinical evidence-based guidelines, industry standard Utilization Management criteria (Milliman Care Guidelines), Medicare and coverage guidelines, health claims processing, medical coding

·        Excellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capability

·        Computer and organizational skills required, ability to manage competing priorities, multi-task with results oriented outcomes and work in a fast paced environment. Intermediate skills of Microsoft Office systems preferred.

We offer extraordinary benefits including outstanding health, dental, pension and family benefits for most positions which are paid entirely by the Funds without co-payments, deductibles, or out-of-pocket expenses for covered services. We also offer tuition reimbursement, generous holiday, vacation, and sick leave, as well as a 401K plan.