RN Case Manager

About the role

The RN Case Manager is responsible for managing and supporting Case Management strategies for care coordination of a group of members associated with a Medicare Advantage plan. Duties include visiting patients, coordinating with healthcare team members, and assessing, planning, implementing, and evaluating patient care plans.

Responsibilities

• Visit patients (in person and/or telephonic) to ensure proper nursing care.
• Interview or correspond with physicians to correct errors or omissions and investigate questionable claims.
• Consult and coordinate with health care team members to assess, plan, implement and evaluate patient care plans.
• Complete Health Risk Assessments for members as assigned.
• Initiate, update and/or revise care plans as needed.
• Maintain a case load of patients as assigned.
• Evaluate, coordinate, and plan patient care in collaboration with an interdisciplinary health team; reassess and revise plans of care in collaboration with other members of the health care team.
• Provide patient/family education based on identified learning needs utilizing available teaching resources.
• Coordinate outpatient discharge planning based on patient needs, clinical circumstances and benefit coverage.
• Participate in all Managed Care related audits; generate, maintain and track periodic and annual reports/documents via MS Office program, emails to support Care Coordination program.
• Perform improvement projects involving development of monitoring/collection tools, review of medical records, data entry, analysis, and preparation of audit findings and reports.
• Participate in patient care conferences, committee meetings, staff development and educational programs to increase or maintain professional competency.
• Correctly apply medical management criteria.
• Research clinical questions from employers, members and payers as required.
• Educate members on health access options.
• Respond, manage, and resolve day-to-day problems presented in care coordination and communicate effectively with the Facility/Home.

Qualifications/Requirements

• Minimum of 2 years of experience in clinical nursing or rehabilitation for the geriatric population.
• Minimum of 2 years managed care experience required.
• Minimum of 3-5 years’ experience doing case management in a managed care environment, preferably with a managed care organization or like facility.
• Preferred: Bachelor’s Degree in Nursing.
• Current license to practice as a registered nurse in assigned state.
• Current CCM license.
• CPR for Healthcare Professionals certification.
• Current valid driver’s license.
• Current motor vehicle insurance.