About the Position

This position is for a Registered Nurse whose responsibilities will include:

• Identifies, assesses and manages medical cases.  Coordinates case management activities with attending physician, member, UM staff, hospital discharge planners, social workers, and public agencies as required.
• Maintains computer tracking log of all members in the case management program, as well as log of daily activities.
• Develops correspondence for members, PCP’s and ancillary providers regarding benefits of the case management program
• Collaborates with other agencies and makes referrals.
• Actively identifies enrollees and authorizes ancillary services for case management membership, including home care, home infusion, physical/occupational therapy and skill nursing facility admissions; documentation of services.
• Maintains regular communication with state agencies, healthcare, individuals and support systems to promote efficient and well-coordinated quality care.
• Performs admission, concurrent, discharge planning and retrospective reviews utilizing clinical assessment skills to make decisions regarding appropriateness or medical necessity of services.
• Utilizes InterQual criteria to verify appropriateness of admissions.
• Utilizes Assessment, Plan, Implementation and Evaluation (A.P.I.E.) format to document reviews and intervention in member notes within QMACS/QNXT and Inform-a-care; documentation must be specific, detailed and concise.
• Performs on-site case management when necessary to evaluate case complexity and assist in discharge planning needs.
• Develops individual plans of care including assessment of health needs, implementation, monitoring, and evaluation of case outcomes.  Coordinates health services within the scope of available benefits.
• Performs active care coordination in conjunction with PCP’s, SCP’s, and ancillary providers.
• Establish and maintain professional rapport with providers, patients and public agencies.
• Regularly reviews case management plans for continuity of care, facilitates plan modifications as indicated by the case acuity.
• Channels services to network providers, including transfer to out-of-network facilities.  Coordinates necessary services with participation ancillary service providers and public agencies as appropriate.

• Registered Nurse with Bachelor’s Degree in Nursing or Healthcare related field
• 3-plus years RN experience
• 3-plus years discharge planning and home health background
• Certified Case Manager Certification (CCM) within 1 year
• Pediatric experience

Preferred

• Managed Care / Case Management experience
• Previous Medicaid experience
• Computer literacy
• Excellent verbal and written communication skills
• Strong analytical skills