We are actively seeking a highly motivated, innovative, and experienced individual to join our team as the High-Risk Nurse Care Manager. Compensation will be commensurate with experience.
Position Summary:This position serves as an integral part of the member's assigned Integrated Care Team (ICT) and is responsible for intensive care management of high-risk members, care management of services related to the delivery of medical benefits that ensure members' complex medical, behavioral, pharmaceutical and psychosocial needs are met within the established benefit policies and guidelines for the treatment and evaluation of members of a specialized needs plan. The High-Risk Nurse Care Manager must have strong critical thinking skills to provide clinical oversight to the team and to clinical case reviews.
Responsibilities:- Provide a single point of coordination/accountability in managing the care of members designated as high-risk.
- Provide comprehensive needs assessment, develop person centered care plan and coordinate appropriate services to meet the members' treatment, support and psychosocial needs. Provide services to members as needed to meet Care Plan objectives, including facilitating referrals to medical, behavioral health and social assistance entities and other services to support wellness and health care compliance.
- Collaborate with the members' treatment providers and community agencies in assessment, planning, and implementing the member's care plan. Coordinate member access to other services such as home health care, Medical Home, durable medical equipment, hospice care, pharmaceutical, vision, and transportation.
- Promptly review and address any crisis situations that arise for any client with supervisory staff, service network and any other required entities. Review and assist in the resolution of member grievances within required regulatory timeframes.
- Participate in regularly scheduled ICT Meetings. Ensure Amida Care's Integrated Care Model of Care is operationalized within the team structure and that members' complex, multi-disciplinary service needs are met.
- Coordinate access to behavioral healthcare including review of all HCBS (Home and Community-Based Service) plans of care and complete necessary written clinical documentation for response to providers, oversee and logging all transactions.
- Perform daily review of inpatient census to ensure members are receiving care and services in accordance with established clinical guidelines and in the most appropriate care setting. Follow up with members and providers when a need is identified that will support improved health outcomes for behavioral and physical health.
- Communicate with members of the healthcare team to ensure members are receiving services and care in accordance with established clinical guidelines and the Plan's benefit package; review clinical documentation, including laboratory values, to ensure members are receiving appropriate care and implement strategies to address unmet needs as appropriate. Ensure completion of documented care coordination within the Amida Care authorized operating systems.
- Conduct member/provider education on preventative care, Gaps in Care, health promotion, Plan benefits, Utilization Review processes, and available services. Provide education and guidance regarding the appropriate level of care and services based on each member's health status and individual needs.
- Ensure timely and accurate flow of information among the health services teams and other providers.
- Participate in review of quality monitoring data of HIV, CD 4 and viral loads for comprehensive, interdisciplinary care planning. Ensure collection and review of required documentation such as HIV verification and ICT weekly reports.
- Identify and advocate for structural and process changes needed at Program sites, the Plan, or In-Network Providers to improve quality of care and services to members.
- Ensure member confidentiality and adhere to Confidentiality and Health Insurance Portability and Accountability Act (HIPPA) policies and regulations.
- Assist clients, members, and providers in resolving specific issues and refer them to appropriate resources or services as needed.
- Perform other duties as assigned.
EDUCATION REQUIREDEXPERIENCES AND/OR SKILLS REQUIRED- Two (2) years' experience in clinical setting and/or three (3) years' experience in managed care setting.
- Experience working with people living with HIV/AIDS or serious chronic illness, preferred.
- Healthcare and staff leadership experience, preferred.
- Strong knowledge of Microsoft Office (Access, Word and Excel).
- Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
- Demonstrate appropriate behaviors in accordance with the organization's vision, mission, and values.
