Case Manager RN - Nashville, United States - Lucent Health Solutions LLC

Description

Job Description

Case Manager, RN

Full-time/Remote

Job Summary

The Case Manager shall work with the entire Narus team to provide appropriate, comprehensive, and proactive onsite and telephonic case management services and to promote the provision of only the highest quality, most appropriate, cost-effective healthcare to plan participants with chronic or catastrophic illnesses or injuries, in accordance with applicable laws, the CCM/CMSA Standards of Practice, the Narus policies and procedures according to the AAHC/URAC Guidelines.

QUALIFICATIONS:

Registered Nurse with Active, unrestricted multi-state license
5 years or more Clinical Experience

Pediatric experience preferred***

CCM certification preferred or relative experience

Excellent written, telephone, and computer skills

Positive, proactive, team-oriented approach/attitude

Time management and organizational skills, flexible, with the ability to work independently

RESPONSIBILITIES:

The Case Manager, under the direction and supervision of a Certified Case Management (CCM) Professional and acting in a Patient Advocate capacity and according to AAHC/URAC standards, The Case Manager shall perform all phases of the case management process, which shall include:

Assessment

1. Defines role and scope of activities to the patient in a comprehensible manner.
2. Communicates to the patient that the information gathered will be shared with the payer.
3. Gathers consent for case management activities.
4. Determines individual needs based on an assessment that identifies all significant needs related to the Medical condition and care (current diagnosis - primary and secondary, treatment plan and prognosis, projected length of treatment/anticipated cost, physicians - primary and specialists, significant history - patient and family, response to previous treatment, potential problems and complications, patient understanding of diagnosis and prognosis, experimental/controversial treatment, anticipated location of care, medications, need for equipment/supplies/etc., need for ancillary services), the Psychosocial condition and care (language, cultural influences, support systems and significant others, financial status, coping behaviors, compliance issues, living arrangements, home environment, religious beliefs, advance directives, patient goals/plans/wishes, teaching needs, transportation issues, ability to perform self care), the Vocational situation (current vocational status, training/education, desire to return to work, job description, transferable skills, general interests/talents, wage earning abilities), the Payer issues (benefit plan design, PPO'S, policy limits/exclusions, eligibility for additional resources, ability to go outside of policy limits, laws affecting coverage, payer contact), available community resources, and barriers to effective outcomes.
5. Works in a holistic manner, considering both medical and psychosocial issues.
6. Identifies issues that might interfere with the provision of the highest quality, most appropriate, cost-effective care.
7. Keeps in mind that a thorough, objective assessment is necessary to a successful outcome.

Planning:

1. Creates an individualized plan of action based on the assessment, which facilitates the coordination of appropriate and necessary treatment, and services required by the patient.
2. Gives consideration, in developing the plan, to the benefit plan design/coverage options. Sets appropriate, measurable goals.
3. Provides the patient with information to make "informed" decisions, empowering and encouraging the patient to make his own decisions through including him in the planning process.
4. Develops contingency plans.
5. Facilitates communication of the patient's wishes to all members of the health care team.
6. When appropriate, discusses advanced directives.
7. Obtains the acceptance of all parties (patient, family, payer, and providers) prior to instituting the plan.
8. Develops a plan, which advocates for the patient and maximizes benefit dollars.
9. Researches and includes costs of services and use of community resources in plan design.

Implementation:

1. Implements a plan that is based on the assessment. Skillfully negotiates and coordinates care based on the plan developed.
2. Identifies and coordinates resources to ensure success of the plan.
3. Works within the health plan provisions. Refers to only those providers that are familiar or researched to ensure high quality (either through personal knowledge/experience, onsite inspections, conversations with providers, review of accreditations and credentials, networking with other case managers, review of outcomes, statistics, payer, and patient satisfaction).
4. Monitors the provision of the coordinated plan.

Evaluation

1. Evaluates plan on a regular basis to determine effectiveness, patient satisfaction, provider comfort, payer satisfaction, if the plan is meeting the needs of all involved parties (but most particularly-the patient's needs) cost effectiveness, patient compliance with treatment, and the impact on the patient's quality of life.
2. Determines if revisions are required due to changes in medical condition, family status, insurance coverage, etc.
3. Maintains availability and willingness to revise the plan as needed.
4. Continues involvement as active, effective case manager.

1. Maintains well-organized, objective, factual, clear, and concise documentation that reflects what was done on the cases and why it was done, adhering to policies regarding timeliness. Documentation of the plan must include who, what, where, when, why, and costs. Teaching of the patient and family is documented.
2. Performs as a patient advocate, in an ethical manner at all times, incorporating case management concepts and following industry standards and guidelines.
3. Becomes involved in the case management process as early as possible following the onset or diagnosis and maintains involvement throughout the course of the illness or injury (not just episodically), managing a case along the entire spectrum of care (home care, acute care hospital, sub acute, rehabilitation, etc.), coordinating cost effective plans that provide quality and continuity of care while eliminating duplication of services and wasted benefit dollars.
4. Demonstrates effective communication skills, both written and verbal, with all members of the treatment (physicians, providers, patients, families, significant others), employer, and payer team.
5. Adheres to the Quality Assurance standards of the unit at a minimum of 85% of the time, meeting or exceeding unit quality, productivity, procedural, and professional standards, actively participating in the quality improvement program, serving as a resource and a liaison to clients and other departments, reviewing cases for appropriateness of case management and medical management services, continuously improving the case management product and processes through participation in product and resource development, assigned projects, unit meetings, and professional growth opportunities (working to obtain CCM as soon as qualified), functioning as a responsible, positive, team member, promotion of the appropriate use of health care resources throughout the continuum of care through accurate and timely written and oral communications and reports, availability (regularly checking e-mail, regular mail, and telephone/voice mail messages-minimum of every two hours with response within the same workday or at least within one workday), care coordination, and adherence to and optimization of the benefit plan limitations, and working in a professional and ethical manner with all members of the treatment , the employer, and the payer team.

The LCM Case Manager shall be responsible for supporting the Director of Clinical Services, the Director of LCM, the Manager of LCM and, when required, the entire Narus team. The LCM Case Manager shall be responsible for providing all aspects of excellent internal and external customer service and development.

Equal Employment Opportunity Policy Statement

Lucent Health Solutions, Inc. is an Equal Opportunity Employer.