Nurse

POSITION PURPOSE:

This position facilitates effective and appropriate use of health care services by:

 

1.  Identifying high risk and high cost patients with complex medical and/or psychosocial needs, assessing treatment options and opportunities and designing treatment programs to improve the quality and efficacy of care;

2.  Integrating and coordinating the expertise and support of other professionals family members, community agencies, and providers across the health care continuum;

3.  Integrating current best practice guidelines related to catastrophic, acute, and chronic disease management;

4.  Achieving optimal clinical and quality outcomes by effectively managing care and resources;

5.  Serving as a liaison to centers and center staff regarding case/disease management;

6.  Participating in department process improvement efforts;

 

PRINCIPLE DUTIES:

The duties with either an MSW or RN designation indicate that they are the primary responsibility of that discipline; however, all of the principle duties remain applicable to either discipline.

 

A.  Perform review, screening and management of potential case/disease management cases.

B. Complete assessments, plan of care, identify resources and goals with enrollee and family involvement.

C. Assist in resource development for complex cases.

D. Assist in the standardization and completion of psychosocial assessments with complex and or high risk members. (MSW)

E. Assist and consult in enrollee assessment for referral to case, disease, population, or entitlement programs.

 

F.  Maintain enrollee case files in MEDecision and Care Guide QI; recording in a timely and comprehensive manner all-relevant case information and updating the Primary Care Provider, as needed, on the enrollee’s condition and discharge plan.  Documentation will include all case management interventions provided, the rationale for the interventions and, when appropriate, the individual providing information regarding the enrollee’s condition.

G. Evaluate each case for cost savings and quality improvement potential; maintain accurate documentation in a timely manner consistent with department policy and procedures.

H. Assist center medical directors, primary care providers and managed care coordinators in case management of complex outpatient cases using our Case Management Process guidelines. (Case Management RN)

I. Manage and maintain requests for authorization/referrals that require Plan approval for cases being actively managed. (Case Management RN)

J. Enter authorizations for Plan-approved services into claims payment system to insure proper payment of claim. (Case Management RN)

K. Provide clarification and feedback to members and providers as needed on benefit coverage determinations. (Case Management  RN)

L.  Act as an internal consultant to other departments on Case or Disease Management and clinical resource issues.

M. Visit member clinics as needed to assist in education and information gathering for improved outcomes for orur members.

N. Assist in the development of policies and procedures related to the case/disease management function.

O.  Review cases with manager or designee on regular basis to assess goals and review case closure criteria.

P. Participate in peer review and audit activities as required.

Q.  Other duties as assigned.



QUALIFICATIONS:

Education and Training:  

Bachelor of Science in Nursing, Masters in Social Work or Licensed Clinical Social Worker required. Current Washington nursing license if RN is required. 

 

Prior Related Experience: 

2 + years of experience in case or disease management in a managed care environment; 2 + years in community nursing or medical social work required.

Certified Case Manager preferred.

 

Knowledge, Skills and Abilities:

Thorough knowledge of Case Management functions;

· Computer literacy, including familiarity with Windows and Microsoft Office programs;

· Ability to work independently and in a team environment;

· Good problem solving skills;

· Excellent time management skills;

· Excellent written and verbal communication skills and ability to work well with all types of providers/customers;

· Ability to maintain professional demeanor and confidentiality;

· Knowledge of entitlement programs and ability to access.