RN Case Manager

Location: Orange, California
Date Posted: 08-03-2017
Case Manager, RN

Responsible for health care management and coordination within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Coordinates and monitors client’s member’s progress and services to ensure consistent cost effective care that complies with the client’s policy and all state and federal regulations and guidelines. Performs duties mostly telephonically.

General Duties/Responsibilities:
(May include but are not limited to)
 Ensures member access to services appropriate to their health needs.
  1. Identifies, assesses and manages members per established criteria.
  2. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Uses independent judgment to determine appropriateness of such authorizations. Deploys internal and external resources to meet identified needs.
  3. Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
  4. Interfaces with Primary Care Physicians, Hospitalists, Nurse Practitioners and specialists on the development of care management treatment plans.
  5. Negotiates rates of reimbursement, as applicable.
  6. Assists in problem solving with providers, claims or service issues.
  7. Measures the effectiveness of interventions to determine case management outcomes.
  8. Participates and provides feedback in the development of utilization/care management policies and procedures.
  9. Counsels and engages in personal discussions with patients and their families on available care options. Helps them to determine their appropriate and preferred course of action.
Supervisory Responsibilities:

Minimum Requirements:
  1. Minimum Experience:
    1. 5 years of "preferred" clinical case management experience; or any combination of education and experience, which would provide an equivalent background.
  2. Education/Licensure:
    1. BA/BS in a health related field (preferred)
    2. Current, unrestricted RN license in the state for which you are applying

Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
 While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
  1. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
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