Enhanced Community Care Manager - RN

Salary depends on experience
Posted on 11/13/17
Monroeville, PA
5 - 7 years experience
Managed Care & Health Insurance
Salary depends on experience
Posted on 11/13/17

JOB SUMMARY

This job works directly with providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted in relation to quality and care costs. The incumbent could work in a physician’s office, visit physician practices on a routine basis, work within a hospital setting and/or visit the member’s home. This job directly helps members with the highest risk scores to coordinate care and navigate the healthcare system by recommending and/or implementing interventions related to the improvement of medical care and costs.

ESSENTIAL RESPONSIBILITIES

  • Conduct member-facing clinical assessments that address the health and wellness needs of the members with the highest risk scores using a broad set of clinical and motivational interviewing skills with the goal of impacting members’ self-management skills and positive behavior changes which will ultimately positively impact member satisfaction and care costs.
  • Serve as a subject matter expert to both internal and external sources (e.g. members, providers, regulatory agencies, UM and policy) to provide education, consultation, and training.
  • Serve as a resource to guide, mentor, and counsel others in regard to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources.
  • Collaborate, coordinate, and communicate with the member’s treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention.
  • Develop and implement case-or condition-specific plans of care and/or intervention plans, as needed, that can become a part of the member’s medical record to establish short and long-term goals.
  • Establish a plan for regular contact (face-to-face as often as possible) with each member and/or provider to monitor progress toward goals, provide additional education and evaluate the need for modification or change in the plan of care.
  • Proactively incorporate lifestyle improvement opportunities and preventive care into member interactions and coaching
  • Collaborate with the appropriate individuals to offer solutions to refine and improve existing practices or participates in developing performance improvement processes that will enhance member outcomes and operational performance/excellence as well support all strategic initiatives including Health Care Reform and STARS initiatives.
  • Work with providers related to performance measures and activities to educate and influence the behavior of members and providers.
  • Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
  • Other duties as assigned.

QUALIFICATIONS

Minimum

  • Registered Nurse
  • 5 - 7 years of Case Management Experience
  • 5 - 7 years of Clinical Practice Experience
  • 5 - 7 years of Disease/Condition Management Experience

Preferred

  • Bachelor's Degree in Nursing
  • ACM Certification (Accredited Case Manager)
  • Certified Chronic Care Manager (CCM)

TRAVEL REQUIREMENTS

  • 25%

SKILLS

Required

  • Microsoft Excel
  • Communication Skills
  • Collaboration
  • Self Starter
  • Health Education
  • Healthcare Industry
  • Friendly Personality
  • Flexibility

Preferred

  • Data Analysis
  • Statistical Analysis

J110937

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