RN Case Manager at Taunton

Job Description

Under the direction and supervision of the Manager of Case Management and Medical Director at Steward Health Care Network (SHCN), the Ambulatory Nurse Case Manager will assist the Primary Care Physician to ensure the clients ambulatory medical needs are met in the most efficient, cost- effective manner.

Responsibilities:

• Ensures the appropriate delivery of services through Assessment and Case /Problem Identification, Coordination, Planning, Monitoring and Evaluation.
• Identifies clients at high risk for long term/chronic care and collaborates with the health care team to develop and implement suitable life plans.
• Facilitates the delivery of services by establishing relationships with all health care providers, health plans, facilities and community resources insuring appropriate utilization across the continuum of care.
• Has a full understanding of the payors benefits and regulations and works within those reimbursement systems.
• Collaborates with networks physicians to provide quality focused cost-effective interventions to all clients across the continuum of care.
• Establishes relationships with clients and their families as needed to determine and facilitate the provision of services needed.
• Performs Case Management services taking into consideration the clients physical, cultural, social and psychological needs.
• Develops criteria to identify ambulatory clients at risk for high cost/chronic care and intervenes to provide a care plan, which utilizes appropriate resources across the continuum.
• Identifies need for and facilitates the development o ambulatory-based programs to effectively meet the needs of chronically ill and at-risk patients. Coordinates these efforts with SHCN Inpatient Case Management staff.
• Identifies availability of community services for clients who are in need of services that are not skilled.
• Supports SHCN efforts to meet federal and state regulations as well as health plan specific policies and procedures.
• Maintains documentation standards in conjunction with policy and procedures.
• May perform utilization reviews per Interqual Guidelines.
• Participates in committees and meetings, at Steward Hospitals and IPAs.
• Provides consultation and education to the client/family and other health care members as needed.
• Participates in Case Management meetings and educational programs sponsored by Steward Health Care Network Services (SHCN), Steward Hospitals, and health plans.
• Reviews appropriate reports from SHCN & Health Plans to identify claims/authorization issues for reconciliation and determine cost effectiveness.
• Understands & adheres to all health plan & regulatory guidelines including NCQA/CMS/URAC/ERISA.
• Maintains and respects patient confidentiality according to SHCN HIPAA policy and procedures.
• Performs other functions as assigned.

Required Skills & Knowledge:

RN license required; Bachelors degree required; Masters degree preferred.

Three to five years of acute medical/surgical experience plus three to five years of Case Management experience.

Certification in Case Management (CCM) strongly preferred.

Strong knowledge in Microsoft Office applications Word, Excel, Access, PowerPoint.

Understanding of the health care delivery setting.

Possesses strong clinical background in acute or post acute settings with focus on the delivery of high quality and cost effective care.

Demonstrates ability to apply principles of critical thinking.

Knowledge of managed care principles and physician practice.

Knowledge of case management, utilization management, and referral management.

Demonstrates knowledge of managed care concepts for various health plan and capitated programs.

Collaborates with multiple providers to provide quality and cost effective care for risk members.

Maintains information in a confidential manner according to policy.

Job Requirements

 
Country: USA, State: Massachusetts, City: Taunton, Company: Steward Health Care System.