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RN Care Manager - Medicare Advantage

Expired Job

Caresource Youngstown , OH 44501

Posted 2 months ago

Role and Responsibility:

  • Acts as primary point of contact with the member and Primary Care Provider (PCP) and functions in a collaborative team role as an integral member of the interdisciplinary care team (ICT)

  • Provides case management services in accordance with the Case Management Society of America (CMSA) standards of practice for members enrolled within the respective ICDS case management programs

  • Coordinates the care, services and health benefits for selected ICDS member populations

  • Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management

  • Coordinates at minimum, quarterly face-to-face interviews with each ICDS member

  • Works collaboratively with the utilization management department in authorizing approved services

  • Verify eligibility, previous enrollment history, demographics and current health status of each member

  • Complete comprehensive and ongoing physical and behavioral assessments by gathering information from the member, family, provider and other stakeholders

  • Develop and implement care plan, defining specific issues, prioritized goals and interventions as agreed to by all parties

  • Monitor and evaluate care plan on an ongoing basis through member, family, provider and stakeholder contact by modifying the plan as needed in conjunction with the prescribed care plan of the treating physician

  • Facilitate and coordinate services based upon the care treatment plan developed in collaboration with all stakeholders

  • Responsible for interdisciplinary care team coordination and member outcomes

  • Primary point of contact with the member's PCP

  • Provide after hours on call coverage as needed

  • Collaborate with the utilization management department for service authorizations

  • Arrange and coordinate services with community partners to maximize utilization of appropriate community resources and support groups

  • Maintain current and accurate documentation of contacts, treatment plans, case notes, referrals, and assessments in Care Management electronic record according to current accreditation and compliance guidelines

  • Maintain appropriate documentation within protocols and guidelines of the Care Management program and within State, Federal and accreditation standards/guidelines

  • Participate in meetings with providers to inform them of Care Management services and benefits available to members

  • Engage members in Care Management through participating in information collection and assertive outreach, including home visits and telephone calls for members the team is unable to reach

  • Assist in education of member/caregiver regarding healthcare access and benefits, and provide member/caregiver with health education and wellness materials

  • Precept and/or mentor new staff

  • Responsible for ICDS model of care orientation and training of both facility and community providers.

  • Regular travel to conduct member visits, provider visits and community based visits as needed to ensure effective administration of the program

  • Perform any other job related instructions, as requested


Education / Experience:

  • Completion of an accredited Registered Nurse (RN) degree program is required

  • Bachelor's Degree in Nursing (BSN) or equivalent baccalaureate degree in healthcare field is preferred

  • Minimum of three (3) years of clinical experience is required

  • Three (3) years or more Medicaid and/or Medicare managed care experience is preferred

  • Three (3) years as a case manager is preferred

  • Two to three (2-3) years of experience as a charge nurse/preceptor experience is preferred

Required Competencies / Knowledge /

  • Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel skills

  • Ability to operate smart phone, iPad, or other mobile communication devices to ensure productivity and ability to perform essential functions

  • Ability to communicate effectively with a very diverse group of individuals

  • Ability to multi-task and work independently within a team environment

  • Ability to collaborate with other team members to optimize outcomes for members

  • Familiarity of the state and federal healthcare regulations and environment

  • Awareness of community and state support resources for population served

  • Critical listening and thinking skills

  • Decision making and problem solving skills

  • Proper grammar usage

  • Strong organizational and time management skills

  • Proper phone etiquette

  • Customer service oriented

Licensure / Certification:

  • Current, unrestricted RN licensure in state of practice is required

  • Case Management or Managed Care Nurse Certification, such as Certified Case Manager (CCM) through the Commission for Case Management Certification (CCMC) or Certified Managed Care Nurse (CMCN) through the American Association of Managed Care Nurses (AAMCN) is preferred

  • Employment in this position is conditional pending successful clearance of a driver's license record check. If the driver's license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in the position will be terminated

  • To help protect our members and the communities we serve from acquiring communicable diseases, evidence of immunity to Influenza is required for this role. CareSource will provide the Influenza vaccination to required employees annually during Influenza season (October 1 March 31) as a condition of continued employment in this position. Employees hired during Influenza season will have forty five (45) days from their hire date to complete the required vaccination. Any exceptions to this requirement must be reviewed and approved by a member of the Employee Health team.

Working Conditions:

  • General office environment; may be required to sit/stand for long periods of time

  • Mobile Worker: This is a mobile position, meaning that regular travel to different work locations is essential. Will be exposed to weather conditions typical of the location and may be required to stand and/or sit for long periods of time.

  • Reside in the same territory they are assigned to work in ; exceptions may be considered, due to business need

  • May be required to travel greater than 50% of time to perform work duties. A valid driver's license, car, and insurance are necessary for work related travel

  • Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer

  • Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our member and may refer members to other CareSource resources

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RN Care Manager - Medicare Advantage

Expired Job