High Intensity Case Manager, RN

The scope of the High-Risk Case Manager is to effectively manage members on an outpatient basis to ensure the appropriate level-of-care is provided for complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care to prevent re-admissions and ensure that the members’ medical, environmental and psychosocial needs are optimize over the continuum of care.

• Identifies appropriate members for case management and conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
• Develop Individual Care Plan (ICP) by conditions identified in health plan HRA, patient assessment, medical records authorizations / referrals, primary care physician, member, and Interdisciplinary Care Team (ICT).

Setting members prioritized and self-management goals.

• Case Manager’s ability to effectively manage a panel / caseload of high-risk members in collaboration with Nurse Practitioner, Pharmacist, PCP, SPC, health plans and other ICT members.
• Create cases in Essette for each case managed member with appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.
• Provides appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.
• Collaborate with member’s family and physicians for seamless coordination of care and services
• Collaborate and coordinate care with Health plans, Community Based Programs (CBAS), Managed Long Term Supportive Services (MLTSS) and Behavioral Health Providers
• Monitors and evaluate effectiveness of the care management plan and modify as necessary based on members’ progress, changes in condition and to minimize unnecessary utilizations, admissions, and readmissions.
• Interfaces with Medical Director and attends IDT as required.
• Conducts outbound calls to assigned high risk case managed members. Occasional, in person visit may be needed to better facilitate members’ care.
• Collaborate with member, member’s family, and physicians for seamless coordination of care and services.
• Collaborate and coordinate care with health plans, Community Based Programs (CBAS), Multiple Long Term Support Services (MLTSS) and Behavioral Health providers.
• Meet health plans and NCQA requirements in turn-around-time for assessments, care plans and IDTs.

Minimum Education : None.

Minimum Experience : At least two (2) years’ experience in the medical field required. One (1) year experience in a case management role required.

At least two (2) years’ experience in ambulatory case management, preferably in a managed care organization, medical group, or health plan setting required.

Knowledgeable in NCQA requirements preferred.

Req. Certification / Licensure : RN / LVN unrestricted active license required. CCM Certification preferred.