Nurse Case Manager Specialist Hybrid - South East Region - Evernorth Care Group

Summary

The Nurse Case Management Lead Analyst is an integral member of the Care Management department as part of Evernorth Care Group (ENCG) primary care team.

This role is aligned to and supports ENCG Healthcare Centers and clinicians to improve the health of the patients we serve, with a focus on the management of high- and rising-risk, disease burdened members.

The Nurse Case Management Lead Analyst utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members.

The Nurse Case Management Lead Analyst ensures that program objectives are met and supports patients and physician practices in coordinating patient care through transitions, barriers to care, and education.

This role additionally connects patients to programs and services as available through ENCG, Health Plan benefits, and within the community.

This position manages a panel of patients coordinating services with them and has oversight of the licensed practical nurses (LPNs) on the team.

This role provides disease management and ongoing follow-up of members with Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD) and other conditions based on patient need.

Primary Location : CJ Harris Tempe with additional coverage in Scottsdale, Central east region and Phoenix Central.

Reports to : Clinical / Operational Supervisor

Direct Reports : No direct reports, but does provide clinical support and oversight to LPN’s and non-clinical staff.

Clinical Responsibilities and Essential Functions

Care Coordination : Coordinates the care of the high-risk, post transition and targeted populations in appropriate, efficient and cost-effective manner.

Assists patient to arrange timely access to services, evaluates social / financial / environmental support adequacy in a culturally sensitive manner.

Care Planning : Collaboratively creates / updates care plans for care transitions, disease management, and other as needed.

Evaluates the effectiveness / relevance of the treatment plan and communicates with the primary care provider and health care delivery team.

Seeks input from health care team members and physicians as able in order to update care plan. Prepares for and participates in care team huddles / meetings to problem solve around highly complex care needs.

Disease Management / Outreach : Initiate new customer and ongoing telephonic connections per protocol for an identified caseload.

Build care relationships among patients / caregivers. Completes post-discharge calls to all identified patients to facilitate and oversee discharge planning coordination of care needs, identifying and closing gaps in care, and providing education within specified timeframes.

Use of Internal / External Resources : Identifies and refers appropriate patients to eligible programs within ENCG and respective Arizona health plans.

Review and inform the patient / caregiver around options for care, use of benefits and community resources. Act as the community resource expert for patients / practices for high-risk members, including transition of care / hospice resources, direct acute admits, direct skilled nursing admits, home health / infusion needs and durable medical equipment.

Serve as the contact point, advocate and informational resource for patient / caregiver. Utilize known community resources to link patient with services / programs available.

Clinical Knowledge : Maintains current knowledge base on the critical elements of the target population such as disease states, quality standards, utilization patterns, clinical treatment guidelines.

Targeted disease states include but are not limited to COPD, CHF, DM, and depression. Coordinates and identifies high-risk population with a history of poly-pharmacy, to improve quality outcomes with appropriate support services in managing pharmacy needs.

Documentation : Maintains appropriate documentation and tracking as required by ENCG and the Care Management department.

Other duties : Fulfills the need of clinical supervision of the LPN reviewing care plans and assessment of patient’s needs.

Represent ENCG and the Care Management department as a member of a cross-functional project team. Other duties as assigned.

Minimum Qualifications

• Current AZ RN License required
• Minimum of 4-5 years nursing experience is preferred
• Experience in cardiac / pulmonary / diabetes nursing preferred
• Case Management / Care Coordination / Disease Management experience preferred
• Certification in related field preferred
• Excellent oral and written communication skills
• Experience with electronic health record documentation
• Experience with cross-functional team collaborations, workflows, and process improvement
• Strong competencies in Microsoft Word and Excel
• Must be able to work in a team environment and exhibit flexibility and enthusiasm in learning new information and developing new skills quickly
• Demonstrate commitment to ongoing education
• Must we willing and able to travel to all affiliated practice locations
• Demonstrated ability in working with Licensed Practical Nurses as part of the care delivery team

Physical Demands / Environmental Factors

• Adequate hearing and visual acuity, including adequate color vision
• Requires fine motor skills, adequate eye hand coordination, and ability to grasp / handle objects
• May be required to lift 50 pounds
• Needs to communicate effectively in-person and telephonically
• Use of computers will be required
30+ days ago