We are representing a Registered Nurse opportunity with a leading healthcare company.
The Care Management Nurse is responsible for the Case Management of High Risk ESRD patients. This includes Care Transitions, Health Risk Assessments, Plans of Care and Interdisciplinary Care Team Conferences. The position is also responsible for the Prior Authorization of Service Requests for your Case Managed members. The Care Management Nurse works with Concurrent Review Nurses and Care Coordinators to assist in meeting patient’s needs.
- Utilize clinical judgment, independent analysis, critical thinking, time management and detailed knowledge of the Care Navigation Program to facilitate the coordination of care for patients.
- Collaborate with clinical and non-clinical staff and other members of the patient’s health care team to develop an individual plan of care to facilitate an immediate action plan to meet the patient’s current needs.
- Communicate and coordinate with patient, appropriate members of patient’s health care team in developing, executing and reviewing results of care coordination efforts.
- Collect, review and employ all pertinent medical information available, care management notes, hospital discharge information, physician clinical information and patient reported health status.
- Assess patient condition, in conjunction with clinic staff, such as the discovery of unreported medical or social conditions or changes at home that may lead to adverse outcomes and ensures that these are referred to appropriate sources for attention.
- Process Prior Authorization requests for medical necessity of Outpatient services including Rehab, Home Health and DME.
- Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilize evidence based criteria that incorporates current and validated clinical research findings. Practice within the scope of their license.
- Identify barriers to efficient utilization and facilitate resolution.
- Collaborate with other departments to resolve claims, quality of care, member or provider issues.
- Identify problems or needed changes, recommends resolution, and participates in quality improvement efforts.
- Maintain and enhance relationships between the business and the provider community.
- Provide consistent and accurate documentation.
- Plan, organize and prioritize assignments to comply with performance standards, corporate goals, and established timelines.
- Consult with physician advisors to ensure clinically appropriate determinations.
- Work within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost effective means.
- Other duties as assigned.
- Bachelor’s Degree in Nursing, preferred
- Registered Nurse (RN). Must have current unrestricted nursing licensure in practicing State with ability to obtain licensure in multiple states.
- 2 – 5 years’ related experience; or an advanced degree without experience; or equivalent directly related work experience.
- Must exhibit leadership skills and behaviors and be able to collaborate with both clinical and non-clinical team members to facilitate desired care coordination outcome.
- Clear and persuasive patient communication skills.
- Previous successful call center, problem solving and budgeting experience, preferred
- Excellent verbal, written and meeting presentation skills
- Successful project management, preferred
- Excellent analytical and leadership skills
- Proficient in word processing, spreadsheet, database, presentation and email applications.
- Organized and detail oriented with a strong bias for follow-up and problem resolution
- Proven ability to be a team player.
Note: Qualified candidates will be contacted within 2 business days of application. If an applicant does not meet the above criteria, we will keep your resume on file for future opportunities and may contact you for further discussion.