Healthcare Innovations RN Specialist
Location: Baton Rouge, LA
Overview:
Responsible for organizing, coordinating, and providing care coordination services to members who are most at risk for health deterioration, sentinel events, and/or poor outcomes. Manage acute and chronically ill members to improve health and financial outcomes through analysis of needs, design, and delivery of interventions. Utilize a collaborative process to assess, plan, implement, monitor, and evaluate options and services required to meet the member’s healthcare needs to address gaps in care. Through communication, the nurse will identify available resources and collaborate with providers to promote quality, cost effective outcomes. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.
Nature and Scope:
This role does not manage people This role reports to this job: MANAGER, Healthcare Innovations
Necessary Contacts:
To effectively fulfill this position, the incumbent must be in contact with: Benefits Administration, Medical Director, Underwriting, Group leaders, Delegated Vendors, Legal Department and other employees as needed, physicians/staff, hospital administrators/staff, providers, caregivers, subscribers, community resources.
QUALIFICATIONS
Education
- Bachelor's degree in nursing or business-related field is required or
- RN license can be used in lieu of a Bachelor's degree
- Four years of related experience can be used in lieu of a Bachelor’s degree.
Degree and current nursing license valid in Louisiana. - Specialist I: Licensed Practical Nurse (LPN) after completion of appropriate education program. - Specialist II: Registered Nurse (RN) with associate or bachelor’s degree from an accredited program. Licenses and Certifications
- Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure Registered Nurse licensed to practice in the State of Louisiana required
- Quality and/or Managed Care certification such Certified Professional in Healthcare Quality(CPHQ), Certified Managed Care Nurse (CMCN), Certified Healthcare Quality and Management (CHCQM), Green or Black Belt Lean Six Sigma preferred
Clinician is expected to have an unencumbered license to practice within the state of Louisiana. The position is tiered based on clinician’s licensure status at time of hire, an LPN will be offered a Specialist I role while an RN will be offered a Specialist II.
Work Experience:
4 - 3 years of recent direct patient care/clinical experience (3 required, 4 preferred). 2 years of experience in managed care is preferred. Experience should include use of behavioral interviewing techniques and theory.
Skills and Abilities
Requires the ability to prioritize, work independently and anticipate needs to make decisions. Ability to plan, implement and evaluate appropriate healthcare services in conjunction with a physician treatment plan and evaluate the effectiveness of alternate care services are required. Requires the ability to research and analyze contracts/cases and make appropriate quality and cost effective decisions.
Knowledge of standardized code sets and medical terminology is required. Must demonstrate excellent interpersonal, organizational, analytical, and telephonic skills. Must demonstrate strong communication skills, including the ability to effectively explain/present claims information and procedures to persons with varied levels of insurance/benefits understanding. Requires working knowledge of related software and office equipment.
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
In a culturally competent and confidential manner, assess member’s status by collecting in-depth information about the member’s situation and functioning to identify individual needs in order to develop and implement a comprehensive case management plan.
Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators. The Healthcare Innovations Specialist will act as an advocate for the member/family, maintaining privacy, confidentiality and safety, building relationships with all relevant parties, supporting informed decision making and facilitating access to necessary and appropriate healthcare services across the continuum of care.
Implement specific activities and/or interventions and evaluate effectiveness that will lead to addressing the member’s gaps in care. Implement a plan to assist members and their family members with gap closure of healthcare needs. Coordinate by collaborating with the member/family, providers, third party payors, employers and community resources to organize, integrate, and modify the resources necessary to accomplish the goals.
Interacts with patients and/or providers to determine patient care needs, compliance and effectiveness with planned interventions and conduct case conferences as appropriate.
Establish care plans as applicable. Evaluates the care plan’s effectiveness in reaching desired outcomes and goals. Modifies any or all the care plan’s components if necessary.
Utilizes behavioral interviewing techniques.
Familiar with guidelines and requirements for authorizations of services related to coordination of care for complex cases. Knowledge of the process for referral to Population Health for possible enrollment in case management process and basic preventative care guidelines.
Responsible for meeting individual quality performance standards and annual targets for program performance, such as monthly productivity, as mutually agreed to by management team to maximize program value. Able to maintain and update documents to share outreach progress.
Participates in Quality Improvement projects and data collection to determine effectiveness of interventions.
Additional Accountabilities and Essential Functions The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions Perform other job-related duties as assigned, within your scope of responsibilities. Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required.
