Job DescriptionJob Summary:
Manages the development, implementation and evaluation of the cavitation care management service lines. Enhances the quality of member management by promoting continuity of care and cost effectiveness through whole person in-patient and out-patient management, care integration, case management, utilization review and care planning.
Job Requirements:
Education and Work Experience:
- Bachelor's Degree in Nursing (BSN): Preferred
- Nursing experience: Preferred
Licenses/Certifications:
- Certified Case Manager (CCM): Preferred
- Registered Nurse (RN) licensure in the state of practice: Required
Essential Functions:
- Partners with internal and external physician advisors, as well as claims department and data management and analytics department to provide safeguards, processes and expected outcomes for the Health Plan's member population. Perform and/or coordinate preventative care, wellness, and nutritional counseling to Members. Develops and maintains positive relationships with customers internal and external.
- Works collaboratively with physicians, staff and service line leadership on quality and performance improvement activities related to optimal utilization of resources, efficient delivery of high quality care, patient flow, capacity management and other clinical cost reduction initiatives.
- Performs ongoing collaboration with staff to ensure a member's medical condition meets medical necessity criteria. Communicates changes that could affect the discharge plan of care.
- Manages communication related to discharge planning and utilization management. Performs ongoing collaboration with staff to ensure condition meets medical necessity criteria.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
