Nurse RN 1

Responsibilities

• Research and design treatment/care plans to promote quality of care, cost-effective health care services based on medical necessity complying with contract for each appropriate plan type.
• Initiate timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all ages.
• This role will focus on the population that was unable to be reached or declined to complete a HRA.
• Determine appropriateness of referral for CM services, mental health, and social services.
• Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
• Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
• Manage member treatment to meet recommended length of stay.
• Ensure DC planning at levels of care appropriate for the members' needs and acuity.
• Assess members' health behaviors, cultural influences and clients belief/value system.
• Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers.
• Research opportunities for improvement in assessment methodology and actively promote continuous improvement.
• Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.
• Determine realistic goals and objectives and provide appropriate alternatives.
• Actively solicit client's involvement.
• Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
• Adjust plans or create contingency plans as necessary.
• Assess and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis.
• Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.
• Develop appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
• Recognize need for contingency plans throughout the healthcare process.
• Develop and implement the plan of care based on accurate assessment of the members and current of proposed treatment.

Skills

• Managed Care, specifically DSNP (required)
• Microsoft Application proficiency (required)
• Excellent organization, documentation (required)
• Transitions of Care (preferred)
• Case Management Experience 3 years (preferred)
• BSN (preferred)
• Use of medical records over multiple applications (required)

Qualifications

• RN Education Requirement
• RN Certification (required)
• LVN is a disqualifier/dislike on resumes