ROLE AND RESPONSIBILITIES

The role of the care management nurse is to coordinate continuity of care for patients often as a liaison between the patient’s family and healthcare organization, ensuring that the proper treatment is administered at the appropriate time to maximize health and well-being while also minimizing the need for hospitalization. The Care Manager strives to promote self-managed care and the use of healthcare resources in the most cost-effective way possible, working with patients of all ages and conditions, but primarily focusing on a specific population. The individual in this position has overall responsibility for overseeing the clinical plan of care to conform to evidence-based practice and regulatory requirements. This position integrates care coordination, utilization management, and discharge planning.

CORE FUNCTIONS

• Identifies members appropriate for Care Management by use of targeted chronic conditions, level of care, and recognition of member’s disease specific and preventative measures, knowledge base or deficits in monitoring health, wellness and chronic conditions. Reviews and analyzes clinical indicators and whether there is any ‘gap’ in compliance that will result in member contact.
• Performs on site or telephonic continued stay review on all of members at predetermined interval during facility stays to collect in-depth information regarding the member’s situation, functioning, and needs assessment to develop a comprehensive Medical Management Plan.
• Develops and implements a plan of care.
• Monitors the plan of care to determine if the goals are being met on an ongoing basis to evaluate for needed changes and updates the plan of care accordingly. Closes the plan of care when complete.
• Applies appropriate criteria for each level of care.
• Collaborates with Medical Director when appropriate (i.e., communicates review findings, criteria not met, use of alternative care settings, determination of appropriate level of care, delay of provision of services, etc.) to insure appropriate, coordinated service delivery.
• Identifies members requiring post hospital services and initiates discharge planning with attending physician and designated hospital personnel.
• Coordinates appropriate post hospital services.
• Conducts outbound calls to members to complete telephonic assessments and provide interventions and education for the management of their health, wellness and chronic conditions.
• Collaborates with the Provider or their designee to address the plan of care from an integrated approach.
• Identifies and reports quality of care issues to the Medical Director and the VP of Medical Management.
• Communicates and collaborates with Medical and Nursing staff. Promotes the mission, philosophy, goals, and policies of the company through staff education.
• Completes clear and concise documentation in Care Management programs.
• Participates in weekly Complex Case Review.
• Provides clinical oversight of the care plan and care coordination process implemented by Care Coordinator Assistants.
• Maintain personal professional development.
• Performs other duties as assigned.
• Reviews requests for Organizational Determinations using appropriate criteria. May authorize according to policy and procedure. Refer to Medical Director all referrals that do not meet criteria.
• Additionally, performs retrospective review on members admitted and discharged over the weekend or holidays as well as reviews all non-pre-authorized admissions.
• Issues denials, after review and direction from Medical Director, in a timely fashion and notifies all parties affected verbally and/or in writing within specified time frames.
• Identifies and reports potential subrogation, workmen’s compensation, and potential loss cases to the appropriate departments.
• Works closely with the referral coordinator to keep all data entry accurate and up to date. Monitors delegated review activities as outline in each individual agreement.

QUALIFICATIONS AND EDUCATION REQUIREMENTS

• Must possess a current and active nursing license to practice in the state assigned or maintain a compact license.
• RN license preferred.
• CCM highly desirable.
• Three years of various clinical experiences.
• Ability to utilize nursing skills to understand and coordinate care of those members that are significantly physically compromised by their illness and/or disability.
• Accountable and autonomous.
• Ability to handle multiple demands of diverse workload and prioritizes critical issues.
• Ability to effectively communicate verbally and in writing.
• Ability to build effective collegial relationships.
• Ability to influence and effect change.
• Ability to analyze and think critically.
• Possesses current knowledge of disease pathophysiology, psychosocial issues, and treatment.
• Good time management skills.
• Positive, service-oriented attitude.
• High level of integrity.
• Computer literate.

Must maintain valid driver’s license and vehicle.

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