RN Care Manager

POSITION DUTIES & RESPONSIBILITIES

• Participates in outreach to Medicare Advantage (MA) members for the Telephonic Care Management Program, including in-home, facility or community visits for members when clinically indicated and in support of Complex Care Management goals.
• Performs ED follow-up calls.
• Facilitates member/family/caregiver education through referrals to Complex Case Management (CCM), Palliative Care (PC), and Telephonic Care Management, and Hospice as appropriate.
• Identifies any psychosocial needs of the member and facilitates referrals to social work and/or behavioral health, as necessary.
• Documents relevant changes in the member’s condition or status, as they occur.
• Completes the initial hospital admission review, and collaborates with AZPC Medical Directors, for medical necessity determination for in-network hospitalized members.
• Performs re-reviews on all status changes, and collaborates with the Medical Director for appropriate status determination.
• Writes appropriate rationales on all reviews that do not meet status requests.
• Performs re-reviews on all disputed Provider Dispute Resolution (PDR’s), and collaborates with the Medical Director for medical necessity determinations.
• Reviews Skilled Nursing Facility, Acute Rehab and Long-Term Acute Care requests for appropriate disposition with the Medical Director, and informs the hospital case manager of decision.
• Affords assistance to the Skilled Nursing Facility with discharge planning to ensure timely and safe discharges.
• Identifies and submits to the Quality Department any potential quality issues for review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
• Identifies and submits Potential Quality Incidents (PQIs) to the Medical Director.
• Equally shares in after-hours, weekend rotation and Holiday coverage for Care Coordination Department.
• Participates in Interdisciplinary Care Team.

EDUCATION, TRAINING AND EXPERIENCE

• Current, unrestricted AZ Nursing license required. – BSN RN preferred.
• Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
• 5 years acute care of care management experience. Medical, ER, Tele, ICE or other relevant clinical role requiring quick critical thinking experience preferred.
• Must have the ability to present clinical information both accurately and confidently.
• Reliable personal transportation with valid driver’s license, current auto insurance, and acceptable driving record required.
• Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
• Able to be detail-oriented, able to function under pressure and able to prioritize and re-prioritize tasks as needed.
• Able to work both independently and as part of a team, with minimal supervision.
• Excellent customer service and communication skills, both oral and written.
• Ability to navigate numerous Electronic Health Records Systems.

COMPENSATION

The hourly range for this position is: $45 – $47.