Case/Disease Management Nurse Navigator

The Health Plan of West Virginia Inc•Wheeling, WV

About The Position

The Case Management/Disease Management Nurse Navigator is responsible for assessing moderate to high risk patients for case management/disease management intervention and coordinating the delivery of cost-effective, quality-based health care services for health plan members by development and implementation of care plans that address individual needs of the member, their benefit plan, and community resources. Directs intervention with moderate to high risk members, and provides education, support and oversight to other team members managing low risk members. Interfaces with providers of medical/behavioral services and equipment to facilitate effective communication, referrals, development of discharge planning and care plan development. Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the care plan. Monitors, evaluates, extends, revises or closes treatment plans as appropriate. Evaluates cases for quality of care. Communicates case management plans and decisions. Understands and follows policies and procedures and performs care coordination duties and documentation in a timely manner. Handles moderate to high risk and/or complex cases. Initiates and leads the multi-disciplinary care planning process.

Requirements

Registered Nurse with at least five (5) years’ experience. Three (3) of those years may be work experience as a nurse’s aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Preferred critical care or other acute care experience.
Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants.
Demonstration of excellent oral, written, telephonic and interpersonal skills.
Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.
Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes.
Possession of a superior work ethic and a commitment to excellence and accountability.
Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.

Nice To Haves

Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable.
Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc.

Responsibilities

Coordinate and provide case management services that are safe, timely, effective, efficient, equitable, and client-centered.
Handle case assignments, perform comprehensive and thorough medical, behavioral, functional and social determinant of health assessments, develop and maintain care plans, review case progress and determine case closure.
Help members achieve wellness and autonomy.
Facilitate multiple care aspects (care coordination, condition education, utilization management, information sharing, redirection/transitional care, cost containment, benefit maximization, etc) across the care continuum inclusive of communications with all relevant multi disciplinary care team members.
Help members make informed decisions by acting as a resource and advocate regarding their clinical status and treatment options.
Develop effective working relations within the industry and cooperate with medical/behavioral team members throughout the entire care coordination process.
Arrange non-benefit services with community based agencies, external social services, health and governmental agencies.
Thoroughly develop and document interactions with patients and families to keep track of their progress towards goals and to ensure satisfaction.
Record case information, complete accurately and timely all necessary referrals, reviews, assessments, care plans, notes, actives, forms and workflows to produce results evidencing adherence to case management interrater review benchmarks and NCQA, CMS and/or BMS regulatory standards as appropriate.
Promote quality and cost-effective interventions and outcomes in accordance with plan benefits.
Assess and address motivational and psychosocial issues.
Adhere to professional standards as outlined by protocols, rules and regulations.