Case Manager RN

Doctors Healthcare Plans•Coral Gables, FL

About The Position

Nurse Case Manager who is responsible for coordinating the continuum of care activities for assigned patients and ensuring optimum utilization of resources, service delivery and compliance with medical regime. This role involves performing and coordinating initial assessments and ongoing reassessments of patient status, documenting case information, performing chart reviews, and participating in case conferences. The Case Manager partners with the Program Director to develop and review individualized care plans, ensuring patients' medical needs are addressed by consulting with physicians, coordinating treatment plans, and advocating for patients. The role also involves promoting understanding of medical factors affecting the target population, identifying and assisting patients in accessing resources, and maintaining accurate patient information for reporting. The Case Manager acts as a liaison between providers and patients, advocates for service accessibility, and participates in outreach activities. Recommendations for program/service changes to meet community needs are also part of the role. Additionally, the Case Manager is expected to complete medication reconciliation upon hospital discharges, follow up on Durable Medical Equipment (DME) or Home Health Care (HHC) needs, and offer community support. Improving coordination of care by facilitating communication among care team members, identifying high-risk members for complex case management, and establishing clinical standards are key functions. Referral of members to internal and external programs, and appropriate coordination of member benefits (e.g., transportation, ambulance usage, DME, home health care) are also required. The role involves steering members towards participating providers, assisting with Medicaid resources, and using professional judgment to determine appropriate levels of care, intensity of service, length of stay, and place of service. Identifying and anticipating problems, developing plans of care with specific objectives, and identifying appropriate healthcare resources are essential. The Case Manager works with the member/family, providers, and healthcare team to develop a plan that enhances clinical outcomes and maximizes member benefits, applying evidence-based guidelines and utilizing community resources. Implementation and coordination of interventions, and continuous reassessment of services to ensure goals are met are ongoing responsibilities. The role aims to improve patient care coordination, reduce barriers, promote timely treatment, empower patients as self-advocates, and assist them in navigating the managed care system.

Requirements

RN Licensure required
Ability to take action in solving problems, exhibiting sound judgement
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts
Demonstrate strong organization and time management skills

Nice To Haves

Managed Care experience preferred
Bi-lingual English and Spanish preferred

Responsibilities

Performs and coordinates the initial assessments and ongoing reassessments of the patient's status.
Documents patient case information within a database system.
Performs chart review/audits monthly or as needed.
Participates in monthly case conferences by providing information pertinent to patient’s needs/ goals.
Partners with the Program Director in development and review of the patient’s individualized coordination of care plan.
Ensures that the patients’ medical needs are addressed; consults with the patients’ physicians as needed, coordinating plans of treatment, and advocating for the patient when necessary.
Promotes understanding of the medical factors affecting the targeted population.
Identifies and assists patient(s) in accessing entitlements, resources, information, and referrals for psychosocial needs.
Maintains accurate and timely patient information, which is readily accessible for review and meets all requirements; assists in data collection for reporting/funding sources.
Help accomplish goals; acts as a liaison between primary care providers, specialist, and/or patient.
Advocates on behalf of patient regarding accessibility of services.
Participates in outreach activities to the entire target population, as directed.
Recommends program/service changes to meet gaps in service in the community.
Performs other duties as assigned/ necessary.
Completes medication reconciliation upon discharges of members when discharge from facilities such hospitals, long term acute centers, skilled nursing facility, and as determined by member needs.
Follow up with the needs of the member when dealing with DME or HHC.
Offer community support when available and pertinent to the members well-being.
Improve coordination of care by facilitating communication between members of the care team, including member, family, healthcare facility, attending physician, primary care physician, specialty, ancillary and other providers (as applicable).
Identify members considered to be high-risk for complicated, long-term, and/or continuous care in order to assure appropriate coordination of care and complex case management intervention with the primary care physician and care team; members have the opportunity to opt-in or opt-out of care management programs.
Establish and maintain clinical standards – preventive health and clinical practice guidelines.
Referral of members to internal and external programs.
Appropriate coordination of member benefits through interventions such as: Transportation, Appropriate approval of ambulance usage, DME and home health care services.
Steering members toward the care of participating and preferred providers.
Assist the member with accessing Medicaid resources, when applicable.
Using professional judgement, independent analysis and critical-thinking skills applies clinical guidelines, policies, benefit plans, etc. to determine the appropriate level of care, intensity of service, length of stay and place of service.
Identifies existing problems; anticipates potential problems and acts to avoid them.
Develops plan of care based upon assessment with specific objectives, goals and interventions designed to meet member’s needs.
Identifies appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities/vendors.
Works with the member/family, provider(s), and other members of the health care team to develop a plan of care that enhances the clinical outcome while maximizing the member’s benefits.
Applies evidence-based guidelines when available.
Effectively utilizes community resources and care alternatives.
Implements and coordinates interventions and other activities that lead to the accomplishment of goals established in the case management plan.
Continually reassesses services delivered to the member to determine if the goals of the plan of care are being met, whether the goals continue to be appropriate and realistic, and what actions may be implemented to enhance positive outcomes.
Monitors information from all relevant sources about the case management plan and interventions to determine the plan’s effectiveness.
Improve coordination of patient care, reduce and remove cultural and healthcare system barriers, promote timely treatment, empower and coach patients to become self-advocates, and assist patients navigate the maze of the managed care delivery system.
Assist SNP Case Manager Director with MBR’s HRA outreach calls.
Be the system navigator and point of contact for patients enrolled in managed care programs, assist patients with benefit coverage and access to care questions/ concerns.
Provide enhanced care coordination services assisting patients in problem solving with issues related to the health care system, financial or social barriers (e.g. transportation as appropriate, prescription drugs formulary assistance, etc.).
Identify and link patients with cultural and community resources to facilitate referrals and respond to social services needs.
Collaborate with other services providers for care coordination and case management activities.
Work with patients over the phone to review and remind their plan of care and progress towards their care management goals.
Conduct outreach activities to assigned members by phone, mail or any other form of communication method to promote program engagement and marketing strategy.
Assist in data collection and report statistical information.
Performs other job duties as required by manager/ supervisor.