Registered Nurse with current unrestricted license in state of residence
Bachelor’s Degree in Nursing preferred
National certification in Case Management desirable
5+ years’ relevant clinical experience
Experience in home care or case management preferred
Proficiency in second language desirable
Experience in specialty areas such as oncology, neurology, chronic condition/disease management a plus
Skill and proficiency in technical concepts and principles; computer software applications
Skilled in assessment, planning, and managing member care
Advanced communication and interpersonal skills
Independent and autonomous with key job functions
Ability to address multiple complex issues
Flexibility and adaptability to changing healthcare environment
Ability to organize and prioritize work and member needs
Demonstration of strong clinical and critical thinking skills
Responsibilities:
Administer assessments, collaborate with the member/caregiver and providers to develop a plan of care, implement member-specific CM interventions, and evaluate plan of care and revise as needed.
Facilitate program enrollment utilizing key motivational interviewing skills
Provide targeted health education, proactive strategies for condition management, and communication with key providers and vendors actively involved in the member’s care
Perform both telephonic and face to face outreach to assess barriers to wellness, medical, behavioral, and psychosocial needs of the member.
Collaborate with member/caregiver and the facility care team to coordinate a safe transition to the next level of care, which includes but is not limited to ensure understanding post-hospital discharge instructions, facilitate needed services and follow-up, and implement strategies to prevent re-admission
Performs case documentation in applicable CM system according to department and regulatory standards
Collaborates and liaises with the interdisciplinary care team, to improve member outcomes (i.e., Utilization Management, Medical Director, pharmacy, community health workers, dementia care specialists, wellness, and BH CM)
Attend and present (as appropriate), high risk members at interdisciplinary rounds forum
Maintain professional growth and development through self-directed learning activities