Complex Care Manager (RN)

HealthTexas Primary Care Doctors•San Antonio, TX

4d•Hybrid

About The Position

The Complex Care Manager (RN) position involves a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes. This position utilizes an interdisciplinary team approach in developing care plans for members, tracks and trends major complex case management benchmarks, and provides patient education in an effort to reduce ER and Hospital Utilization. In addition, this position will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values. At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission “to deliver quality and compassionate care with outstanding service, every patient, every time”. As a Complex Care Manager (RN) HealthTexas we expect you to embody and promote our Values and defined behavioral expectations. Integrity: Do the right thing, the right way, every time. Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality. Compassion: Treat everyone with respect and dignity. Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent. Synergy: Collaborate to improve outcomes. Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas. Stewardship: Use resources responsibly and efficiently. Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.

Requirements

5 years strong clinical background.
Current RN TX licensure required.
Strong computer skills, including MS Word and Excel
Strong oral and written communication
Strong interpersonal and organizational skills
Experience with an Electronic Medical Record and documentation programs.
Experience in telephonic assessments
Case Management experience in either insurance or inpatient setting

Nice To Haves

Prior HMO/Managed Care experience or equivalent experience preferred.
Prior Care Plan development CCM a Plus
BSN preferred.

Responsibilities

Coordinate care needed by members with highly complicated, complex, or catastrophic medical conditions, and in conjunction with the interdisciplinary team, the CCM develops a care plan for meeting those needs in the most cost effective way possible while insuring quality is met working within the parameters of available benefits.
Facilitate access to medically necessary services and ensure that they are provided at the appropriate level of care in a timely manner acting as a liaison between members and all providers to enhance communication and coordination of care.
Provide consistent reporting to Medical Director (s) and management presenting clinical information on current cases, identifying potential cases for ongoing case management and service review, and coordinating care with other Medical Management team members.
Develop a plan of care to include long and short term SMART goals based on problems identified, interventions aimed at assisting the member to meet their goals, education regarding specific care need, assistance to members in reducing barriers in order to maximize positive member outcomes, and evaluation of member’s progress through plan of care implemented.
Develop follow-up mechanisms for outstanding or unresolved requests to ensure that timely care is provided.
Maintain current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms.
Active participation in Quality Improvement through such activities as occurrence reporting, special projects, grievance review, program evaluation, etc.
Assist in documenting policies and procedures for training and replication.
Nurture effective working relations with physicians and staff so they will call on managed care staff as a resource and seek assistance with specific patients.
Monitor productivity and provide constructive feedback when opportunities for improvement are identified.
Set goals for performance and deadlines in ways that comply with company’s plans and vision.
Comply with all guidelines established by the Centers for Medicare and Medicaid (CMS), if applicable.
Other duties may be assigned.