Nursing Job at Medical Professions: RN Case Manager, Managed Care

RN Case Manager, Managed CareDefinition:

Under general supervision, performs case management for members of the various product lines requiring specialized medical care which is life threatening, degenerative or disabling in accordance with State regulations and the company’s guidelines. This case management function relates to medical care which is required over a long period of time. Performs other duties as required. This position provides case management to a targeted group of members, works with the member’s PCP, the company’s UM and QI staff, the member’s family, and other health care providers to coordinate and arrange care to meet the member’s specialized health care needs.

Typical Duties:
Performs case management coordination for members requiring extended access and/or treatment plan development for conditions or diseases that requires specialized medical care over a prolonged period of time, which is life threatening, degenerative or disabling. Monitors and evaluates member needs following state regulations and the company’s guidelines.
Works in partnership with the PCP and the company’s Medical Director in developing a medical treatment plan outlining the individual needs of the member and care coordination goals. Serves as liaison between the Provider network, and the company’s UM and QI staff.
Monitors the progress of the treatment plan through regular progress reports from providers and health care team; maintains ongoing communication with the PCP, ancillary health care providers, and with members and/or member family.

Assesses claims and medical charts for review of medical necessity, cost containment and payment.
May review requests for elective procedures and referral requests for participating and non-participating providers. May assist with out-of-area (OOA) requests for authorizations and obtains all information to confirm the status of provider and member to determine the appropriateness of the referral.

Compiles, enters and updates patient information into the UM system in an accurate, concise and timely manner.

Responds to difficult calls and assists staff members or providers on case management.
Maintains standards of quality and efficiency established by the company and regulatory Agencies. Alerts management staff to member quality of care issues.
Notifies the appropriate departments of Reinsurance issues as identified in the company’s guidelines.

Works as a team player with fellow Utilization Management staff and other departments to promote the mission of the company. Attends monthly UM meetings, prepares and presents appropriate issues and studies.Knowledge of:
Managed care and utilization review process; case management process and evaluation; clinical nursing principles and techniques; disease entities; current medical diagnoses, procedures, treatment, modalities, equipment and supplies; MediCal regulations and services; general and statistical research methods; report writing.Ability to:
Work well under pressure; ability to prioritize and organize work and high volume caseload; exercise good judgment; must be a team player and work effectively with staff, physicians, nursing and community services. Read and interpret rules, regulations, and medical records. Prepare and maintain accurate records; analyze data; prepare clear and concise reports; interpret medical terminology for non-medical personnel and communicate effectively both verbally and in writing.Physical requirements:
Mobility requirements: ability to operate a keyboard; sit for long periods; lift and carry up to 30 lbs; drive; Dexterity requirements: ability to perform repetitive motion; Hearing/talking requirements: ability to hear and talk on the telephone; ability to talk to person; Emotional/ Psychological factors: ability to handle public contact, decision-making, concentration, working alone, working weekends/nights and working overtime.
Requirements
QualificationsEducation: Possession of a current RN license. Additional certification in case management preferred. Experience: Three years of work experience as a RN in a hospital, clinic or managed care environment performing case management. Experience in a managed care environment preferred.