Under general supervision of the Director of Clinical Programs and the Manager Complex Case Management, the RN Complex Nurse case manager is responsible for assessing members with multiple and complex medical conditions who need post discharge care transition and or short term complex case management, Conducts a person centered assessment and identifies barriers to care, develops a person centered My Health Coach Plan, conducts self-management education, ongoing monitoring of signs and symptoms and care coordination and refers to appropriate community services and healthplan services and benefits to minimize barriers to care and the risk or unnecessary admission, readmission or emergency room utilization .
The RN Complex case manager uses techniques such as motivational interviewing, teach back, behavior change, and cognitive behavior techniques to help assigned members establish a medical home, improve medication adherence, understand signs and symptoms and what to do, and self-care education about managing their chronic conditions to improve quality of life and care outcomes.
The RN Complex Nurse case manager supports members working in conjunction with an existing team of Health professionals that includes a Service Coordinator, the members treating physicians, ancillary service providers and may include Clinical Pharmacists, Behavioral Health professionals and Disease Management staff. Prepares for and presents members to Interdisciplinary Care Team (ICT) rounds for difficult to manage cases requiring team recommendations and prior to transitioning from Complex Case Management to Disease Management or Service Coordination.
Case Manager Primary Duties & Responsibilities
Prepares for member outreach by reviewing available medical history including known chronic conditions, whether or not the member is receiving routine chronic and preventive health care, if there are identified medication adherence issues and gaps in care based on predictive modeling reports, services that are in place and reviewing Service Coordination notes and HRA. Conducts Telephonic assessments to identify barriers to care such as the need for LTSS and or Waiver level services, equipment, medication management, self-care education and monitoring and establishing a medical home, community services and housing, establishing a medical home for routine preventive and chronic care management.
Effectively manages a case load of 60 - 100 members and conducts outreach based on departmental policies and as often as necessary to effectively bring about stabilization of medical health and improved quality of care. Completes documentation within 24 hours of outreaches per departmental policies and utilizes approved documentation templates. Assists in the identification of member health education needs and monitors current clinical status by conducting assessments using approved assessment tools, identifying the need for physician or other intervention to prevent avoidable admission or readmission.
Utilizes approved evidence based guidelines and general health and wellness strategies to achieve goals in the overall health of members. Works with members to identify and set personalized health improvement plans and goals and support members in achieving those goals Assesses the member's readiness to change and implements actions to assist members in moving through stages of change to reach their goals. Collaborates with team members such as Clinical pharmacist, Service coordinators, Medical Director, ancillary service providers and member's medical home provider and treating specialist as well as other case managers in order to eliminate or mitigate barriers . Works with members and treating physicians on opportunities to close gaps of care and to improve the member's overall health status Empowers members with skills to provide enhanced interaction with their treating physicians such as preparing the member for the physician visit and writing down questions and concerns that they would like to discuss or clarify.
Collaborates with Cigna HealthSpring Star+Plus UM discharge case managers to facilitate effective communication for members with multiple and complex medical conditions at higher risk of readmission assigned for post discharge transitions of care for the purposes of assisting with community resources, DME providers, referrals, housing and other related duties. Conducts post discharge assessments for assigned members in accordance with policy and refers members to DM Managers who are in need of a face to face visit due to inability to locate the member after multiple attempts, when successful interaction via telephone with the member has not been successful and when clinically indicated to determine scope of problem and environmental and social contributing factors Collaborates with the member/family, physician, and health care providers/suppliers to discuss and prioritize the plan of care and prescribed treatment plan in accordance with evidenced based medicine and identified long and short term goals Outreaches to obtain clinical records as necessary to establish the prescribed treatment plan, obtain results of tests and x-rays and other necessary clinical information for the purpose of treatment planning and operations. Develops, monitors, and evaluates the My Health Coach Plan of Care, extends, revises or closes the plan of care according to Interdisciplinary care team recommendations and communicates case management decisions.
Communicates with the Service Coordinator, Disease Management Case Manager in preparation of transitioning from complex case management. Consults with BH team members in cases where a member's behavioral health or emotional issues are impacting their ability to set and/or achieve goals Understands and follows policies and procedures, completes documentation of interactions and interventions of assigned members in the QNXT case record and SC Web app or other systems as it applies using approved note templates, produces and submit reports in a timely manner and in accordance with workflows and policies Actively participates in interdisciplinary care teams; assures appropriate documentation in QNXT and SC Webapp and that My Health Coach Plans are current prior to scheduled ICT meetings. Performs other related duties incidental to the work described herein
Ideal candidate must live in McAllen, Texas area,
Current licensure as a Registered Nurse (RN) in applicable state or active license in a state allowing "multistate privilege to practice". Three or more years of clinical experience and two or more years of experience in case management and knowledge of chronic conditions (Diabetes, CHF, CAD and hypertension, COPD and Asthma, Renal Disease and mental health conditions including depression, bipolar disease).
Proficiency in Microsoft Office Word, Excel and windows based systems.
Excellent written and verbal skills in communicating with Members, Caregivers and providers
Certification as Case Manager or will agree to become certified within one year of hire.
Previous STAR+PLUS Medicaid and or Medicare Managed Care experience.
Prior experience and knowledge of making referrals to community resource organizations.
Three or more years' experience in clinical case management of members with multiple and complex chronic conditions
Experience in telephonic counseling/coaching preferred.
Good problem solving skills and the ability to triage based on severity
Excellent interpersonal skills and the ability to work in a team environment.
Bilingual English-Spanish Highly Preferred.
Must be able to sit and work on a computer and use telephone for the majority of the work day.
Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve.
We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.
When you work with Cigna, you'll enjoy meaningful career experiences that enrich people's lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require an accommodation based on your physical or mental disability please email: SeeYourself@cigna.com. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.