JOB SUMMARY:
The RN Case Manager Team Lead is primarily responsible for the daily management and support of the Case Management strategies for care coordination for a group of members associated with a Medicare Advantage plan. This position will consult and coordinate with health care team members to assess, plan, implement and evaluate patient care plans.
ESSENTIAL JOB DUTIES:
To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.
• Hire and assist in training for all new RN Case Managers as indicated
• Monitor Health Risk Assessments for members; complete if needed for compliance with model of care
• Monitor care plan completion
• Provide education based on identified learning needs utilizing available teaching resources to members of the home/facility staff as needed
• Monitor and coordinate outpatient discharge planning based on patient needs, clinical circumstances, and benefit coverage
• Participate in all managed care related audits
• Generate, maintain, and track periodic and annual reports/documents via MS Office program, e-mails to support care coordination program.
• Manage all patient transfers within the market
• Prepare and conduct weekly case conferences
• Track/assist all Part A authorizations
• Complete discharge planning for all inpatients and LTACH
• Provide updates and records to UM as needed
• Reconcile authorizations with UM for accuracy
• Oversee authorization education and oversight for specialists and medications
• Monitor ICP/ICT coding
• Perform quality audits for compliance
• Perform improvement projects involving the development of monitoring/collection tools, review of medical records, data entry, analysis, and preparation of audit findings and reports
• Participate in patient care conferences, committee meetings, staff development and educational programs to increase or maintain professional competency
• Apply medical management criteria accurately
• Research clinical questions from employers, members and payers as required
• Respond, manage, and resolve day-to-day problems presented in care coordination; communicates effectively with the facility/home
• Conducts for 1:1 with RN/CM team
• Other duties as assigned
JOB REQUIREMENTS:
• Punctuality, reliability
• Successful completion of required training
• Manage stress appropriately
• Handle multiple priorities effectively
• Independent discretion/decision making
• Make decisions under pressure
• Multi-task, meet deadlines, prioritize
Required Computer Software/Equipment used:
• Various operating systems
• Standard office equipment
• Microsoft Suite applications
REQUIRED QUALIFICATIONS:
• Education:
o Graduate from an accredited Registered Nursing Program
o Bachelor's degree preferred
• Experience:
o Two (2) years' experience in clinical nursing or rehabilitation for the geriatric population
o Two (2) years' experience in managed care required
o 3-5 years' experience performing case management within a managed care environment, preferably with a managed care organization or like facility
• License/Certification(s):
o Current state Registered Nursing License
o Current CCM license preferred
o CPR license
o Current and valid driver's license
o Current automobile insurance according to company policy
SUPERVISORY RESPONSIBILITES:
• Maintain staff by orienting and training employees
• Supervise other RN Case Managers as required
• Supervise direct reports to ensure compliance
• Occasionally needs manager's direction due to extraordinary circumstances
WORKING CONDITIONS:
• Audio-Visual: Good
• Hearing: Good
• Ability to lift to 40 pounds
• Subject to standing, walking, sitting, bending, reaching, kneeling, pushing, pulling; use of hands
• Work is typically performed in a standard office environment; well-lit; comfortable temperature-controlled; above-average conversational noise is frequent
• Position may require flexible hours, unscheduled overtime or occasional week-end work
• Travel may be required
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EQUAL OPPORTUNITY EMPLOYER
This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.
Education Preferred
- Bachelors or better in Nursing
- Associates or better in Nursing
Licenses & Certifications Required
Preferred
- CPR Certification
- Driver License
