Care Manager – Registered Nurse

Duties and Responsibilities

• Evaluates patients for care management services, determines appropriate level of care coordination management for the patient
• Completes a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgement to evaluate needs for alternative services as needed
• Works collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to create a person-centered care plan with measurable SMART goals
• Maintains and updates care plan to include progress towards achieving established goals and self-management activities
• Interacts with patient, family and providers and multidisciplinary care team to assess the options of care including use of benefits ad community resources to update care plan
• Utilizes developed systems, processes, and initiatives to engage patients in relevant case management activities necessary to promote wellness and care at the right place and time
• Works collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to support patient adherence to medical plan of care
• Supervises and acts as a resource for non-clinical staff [i.e. care coordinators, social workers]
• Verifies that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team
• Coordinates necessary referrals and authorizations within care management areas
• Facilitates the information flow between hospitals, long-term care, specialists and home health representatives and the care team
• Uses available data and works with physician and office staff to help identify high risk, high need, and potentially high-cost patients
• Carefully coordinates care and communicates with multiple providers, internal and external to the practice
• Identifies and utilizes cultural and community resources and aligns with the patient’s cultural preferences as much as possible
• Verifies that members are screened for behavioral health concerns (depression / substance abuse) and are receiving appropriate screening and behavioral health interventions
• Facilitates any necessary follow-up behavioral health needs with local behavioral health providers
• Attends required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled
• Provides and facilitates open communication, regarding patient status, with physicians and office staff
• Obtains records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts
• Develops constructive relationships with internal population health team members, participating providers, and community resources
• Performs other job-related duties as assigned

Qualifications

• Compact RN License – California and NY Licensure preferred in addition
• Bachelor’s degree in nursing preferred; Associate degree in nursing is minimum requirement
• 1-2 years’ experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, ambulatory care management, or managed health plan
• PREFERRED: Certified Case Management (CCM) certification
• PREFERRED: Care/Case Management experience
• Working Knowledge Of The Following Required:
• Principles of utilization management;
• care management principles;
• basic knowledge of health plan contracts and benefit eligibility requirements;
• Hospital structures, Managed Care and payment systems
• Timely and accurate documentation of day-to-day activities in designated technology platform
• Adaptable to new technologies and software
• Proficiency in EMR system(s), Outlook and data entry experience preferred
• Basic PC skills (MS Word/Outlook/PPT/Excel)

About COPE Health Solutions

COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers.

CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers.

To learn more about COPE Health Solutions, visit CopeHealthSolutions.com.