RN Care Manager

UHS•McAllen, TX

11h

About The Position

Under the supervision of the Care Management Clinical Program Manager, the RN 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, social-economic, or mental health needs. 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 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 Care Manager will adhere to the CMSA Standards of Practice for Case Management. The RN 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 Care Manager assesses the member’s needs, and creates and monitors a specific individualized care plan, including end of life planning. The RN 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 and support agencies. 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.
Minimum of three (3) years in clinical nursing practice, required.
Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada, Texas and/or Florida), required

Nice To Haves

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.
Certified Case Manager (CCM), Case Management Nurse – Board Certified (CMGT-BC), Accredited Case Manager – RN (ACM-RN), or Certified Managed Care Nurse (CMCN)
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.
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 end of life 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 and support agencies.
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.