Location: California-Los Angeles
Duration: Full Time
Job ID: 4549 (21454344)
Category: Managed Care RN Job
Contact: Kat Forester
Job Salary: Competitive
Job Posted: 01/26/21
Care Management Nurse Specialist, RN - 4549 (21454344)
- Performs essential functions of Care Management programs (complex, high risk, disease management) for identified and assigned member population according to HIPAA guidelines.
- Manages a specified caseload; coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner.
- Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit.
- Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team.
- Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines.
- Uses claims processing and Care Management software to look up member information, document contacts, and track member progress.
- This position will engage members telephonically, face to face in the Family Resource Center or home visits.
Primary duties may include, but are not limited to:
- Evaluate information regarding prospective members referred to Care Management by internal and external sources such as HRA, Predictive modeling, PCP and PPG referrals, HHP eligible members etc. to determine appropriate level or Care Management interventions to meet the member needs.
- Conducts assessments to identify member needs and develops individualized care plan. This will be conducted telephonically, face to face in the Family Resource Center (FRC)/Community Based Organization (CBO).
- Documents in appropriate applications to meet contractual and regulatory requirements.
- Ensure member access to services appropriate to their health care needs.
- Implements care plan by facilitating referrals as appropriate within benefit structure.
- Coordinates internal and external resources to meet member's identified needs.
- Encourages member and family empowerment through education and use of reliable resources.
- Interfaces with Interdisciplinary Care Team reviewing the care plan and making any modifications to the care plan based on the recommendations.
- Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
- Precepts new and current staff as needed based on departmental needs.
- Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training.
- Travels to FRC for in-person Care Management activities. Provides onsite follow-up with members at FRC at planned intervals and as needed based on patient status.
- Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) regarding benefit approvals and denials. Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines.
- Perform other duties as assigned.
Required Education / Experience / Certifications:
- Associate's or Bachelor's degree in Nursing
- Additional years of qualifying work experience may be considered in lieu of Bachelor’s degree.
- With Associate's or Bachelor's Degree (in Nursing): Minimum of 5 years of recent RN Care Management experience in a hospital or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.
- Minimum of 3 years nursing experience in a clinical setting.
- Requires current knowledge of clinical standards of care and disease processes.
- Requires critical thinking skills, effective verbal and written communications skills to consult with physicians and providers.
- Requires the ability to use a personal computer, and knowledge of medical information systems.
- Current and unrestricted CA RN License.
- CCM Certification.
- Must maintain a valid CA driver’s license and show proof of current auto liability insurance.
Preferred Education / Experience:
- Proficiency in language other than English.
- Experience in telephonic assessments and coaching with members who have been diagnosed with a chronic condition, preferably with Medicaid and Medicare population.
- Ability to use motivational interviewing skills with members.