RN Care Manager (Clinic)

About the role

The RN In-Clinic Care Manager is responsible for providing care management services for medically and/or socially complex members. The target member population includes individuals with complex medical conditions, multiple hospital readmissions, social-economic, or mental health needs panelled to a specific provider group.

Responsibilities

• Provide care management services for medically and/or socially complex members.
• Develop comprehensive care plans for members and family self-care competence, including motivational assessment, assessing for desired level of involvement, and coaching for adherence to the care plan.
• Achieve optimal health and/or independence in managing care for high-risk and high-need members.
• Assess the member’s needs, and create and monitor a specific individualized care plan, including advance care planning.
• Promote knowledge of the Care Management program to Prominence Health Plan contracted physicians, as well as members.
• Develop and sustain partnerships with community resources, support agencies, and support initiatives of Prominence.
• Participate in efforts associated with the successful implementation and operation of the SNP CM program and ensure the model of care (MOC) meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS), state Medicaid offices (as relevant), and NCQA.

Requirements

• Associate or Bachelor’s Degree in Nursing, required.
• Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada) required.
• Minimum of three (3) years in clinical nursing practice, required.
• Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
• Recent working knowledge of Milliman Care Guidelines, preferred.

Qualifications

• Recent working knowledge of Milliman Care Guidelines, preferred.
• Knowledge of Medicare/ Medicaid processes and compliance standards, preferred.
• Strong clinical triage skills - easily able to triage office hour and post office hour calls to the appropriate level of care.