RN Case Manager
Location: Remote 100%
Duration: 6-7 Months
Note : Concurrent Review expereince mandate
Description:
General Summary:
Case Managers perform a blended function of utilization management (UM) and case management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs.
Determines develops and implements the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of: member inquiry, triage hub, chronic conditions, poly-pharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits.
Apply detailed knowledge of Client established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.
CM care typically lasts three months per member/patient.
Requires RN license and CM Certification at all levels.
All levels require > 80% Inter-Rater Reliability ratings, which test knowledge and skills based on hypothetical situations .
Responsibilities:
- Research and designs treatment /care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type.
- Implements discharge (DC) planning activities for medically complex cases.
- Determines appropriateness of referral for CM services.
- Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
- Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
- Manages member treatment in order to meet recommended length of stay.
- Ensures DC planning at levels of care appropriate for the members needs and acuity.
- Negotiates with employer groups when contractually required.
