RN Care Manager (Clinic)

UHS•Reno, NV

14d•Onsite

About The Position

Under the supervision of the Care Management Clinical Program Manager, the RN In-Clinic Care Manager is responsible for providing care management services for medically and/or socially complex members. The target member population includes individuals with complex medical conditions, multiple hospital readmissions, social-economic, or mental health needs panelled to a specific provider group. The goal of the program is to assist these members in achieving optimal health and/or independence in managing their care. To achieve this goal the RN In-Clinic Care Manager will demonstrate and apply knowledge of the philosophy/principles of comprehensive case management, patient-centered, culturally sensitive care coordination, and management of complex members. The RN In-Clinic Care Manager will adhere to the CMSA Standards of Practice for Case Management. The In-Clinic Care Management (CM) Model establishes a fully integrated, clinic-embedded approach designed to enhance care coordination, reduce avoidable utilization, and improve outcomes for high-risk and high-need members. By pairing the primary care practice with a RN Care Manager (RNCM) supported by Care Coordinators, the model provides proactive, data-driven, and patient-centered care management—directly supporting organizational goals across Primary Care and the Health Plan. The RN In-Clinic Care Manager is responsible for developing comprehensive care plans for member and family self-care competence, including motivational assessment, assessing for desired level of involvement, and coaching for adherence to the care plan. The RN In-Clinic Care Manager assesses the member’s needs, and creates and monitors a specific individualized care plan, including advance care planning. The RN In-Clinic Care Manager promotes knowledge of the Care Management program to Prominence Health Plan contracted physicians, as well as members. In addition, s/he is responsible for developing and sustaining partnerships with community resources, support agencies, and supporting the initiatives of Prominence by acting as a liaison between Prominence provider and member to achieve mutual goals. Additionally, the position includes participation in efforts associated with the successful implementation and operation of the SNP CM program and that the model of care (MOC) meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS), state Medicaid offices (as relevant), and NCQA.

Requirements

Associate or Bachelor’s Degree in Nursing, required.
Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada) required
Minimum of three (3) years in clinical nursing practice, required.
Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
Recent working knowledge of Milliman Care Guidelines, preferred.
Experience working with the Medicare and Medicaid population segment, preferred.
Knowledge of Medicare/ Medicaid processes and compliance standards, preferred.
Strong clinical triage skills -easily able to triage office hour and post office hour calls to the appropriate level of care.

Nice To Haves

Certified Case Manager (CCM), Case Management Nurse – Board Certified (CMGT-BC), Accredited Case Manager – RN (ACM-RN), or Certified Managed Care Nurse (CMCN), preferred
Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
Recent working knowledge of Milliman Care Guidelines, preferred.
Experience working with the Medicare and Medicaid population segment, preferred.
Knowledge of Medicare/ Medicaid processes and compliance standards, preferred.

Responsibilities

Providing care management services for medically and/or socially complex members.
Assisting members in achieving optimal health and/or independence in managing their care.
Demonstrating and applying knowledge of the philosophy/principles of comprehensive case management, patient-centered, culturally sensitive care coordination, and management of complex members.
Adhering to the CMSA Standards of Practice for Case Management.
Developing comprehensive care plans for member and family self-care competence, including motivational assessment, assessing for desired level of involvement, and coaching for adherence to the care plan.
Assessing the member’s needs, and creates and monitors a specific individualized care plan, including advance care planning.
Promoting knowledge of the Care Management program to Prominence Health Plan contracted physicians, as well as members.
Developing and sustaining partnerships with community resources, support agencies, and supporting the initiatives of Prominence by acting as a liaison between Prominence provider and member to achieve mutual goals.
Participation in efforts associated with the successful implementation and operation of the SNP CM program and that the model of care (MOC) meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS), state Medicaid offices (as relevant), and NCQA.