Medical Case Manager

Neighborhood Health Plan of RI

Medical Case Manager


Overview: 

The Medical Case Manager works collaboratively with the Health Care Team to manage and coordinate care for a specific population of members whose needs represent high clinical and social risk in order to ensure quality, and cost-effective member-centered care.

Qualifications:  

Required:
- Licensed RN, State of RI
- BS Degree or Certification as a CM or RN with 3 years clinical practice
- 3 years experience in acute care
- Computer literacy with Windows based programs
- Strong organizational and documentation skills
- Excellent Customer Service Orientation
- Strong Interpersonal Skills

Preferred:
- Clinical Specialty Experience
- Medical Review experience helpful
- Case Management certification a plus
- Clinical Specialty certification a plus
- Bilingual (English/Spanish) a plus
- Practice within the scope of his/her license

Duties and Responsibilities: 
Responsibilities include, but are not limited to the following: 

- Practice Case Management within the scope of licensure.
- Utilizes case management principles and sound clinical judgment in coordinating care for a specific member population. 

Performs intensive case management functions for identified individuals in order to promote quality, cost-effective outcomes, including but not limited to:
- Performing a comprehensive assessment
- Care planning activities including the development of interventions, short and long-term goals in collaboration with member, family, PCP, Behavioral Health Professionals and other involved health care professionals and community agencies, as appropriate
- Implements care plan, facilitates referrals, coordinates services and resources and provides ongoing monitoring and re-evaluation of outcomes
- Continuous monitoring and evaluation of the care outcomes and identification of service gaps
- Regular review and revision of the plan of care in collaboration with the family and appropriate members of the health care team based on the outcomes and evaluative findings. 
- Home visits as necessary or required

- Provides comprehensive documentation of all activities and contacts in CMAQE and appropriate software system
- Facilitates referrals and coordinates needed services
- Collaborates with Medical Review Nurse as necessary in identifying needed services and supports
- Calculates cost savings that may result from redirecting member to a more appropriate care setting (i.e. PCP visit rather than ER)
- Communicates with ancillary departments, such as Provider Relations and Member Services, as necessary to meet individual needs of members and providers.
- Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner.
- Takes responsibility for professional development, supports a learning environment, and meets professional competency requirements
- Participates in department continuous quality improvement activities
- Provides clinical oversight to HNS and other team members; providing direct supervision of HNS as appropriate regarding individual case status
- Serves as clinical resource to respond to questions from ancillary departments within Neighborhood
- Provides cross-coverage as assigned by Supervisor
- Participates in outreach/marketing activities as needed and as appropriate
- Other duties as assigned by Supervisor


Neighborhood is an Equal Opportunity Employer