Nurse Case Manager

Nurse Case Manager

Job Description

Description:

The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits. Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

Experience:
3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
Experience preferred managing chronic conditions, such as diabetes, hypertension, and asthma.
Healthcare and/or managed care industry experience required.
Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written.
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
Typical office working environment with productivity and quality expectations.

Assessment of Members:
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services.
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.

Enhancement of Medical Appropriateness and Quality of Care:
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
Identifies and escalates quality of care issues through established channels
Ability to speak to medical and behavioral health professionals to influence appropriate member care.
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
Helps member actively and knowledgably participate with their provider in healthcare decision-making
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.

Monitoring, Evaluation and Documentation of Care:
In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Majority of time is spent on telephonic outreach and documentation in a clinical case management platform.


Duties
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services
Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate
administration of benefits
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

Experience
3 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
Experience managing chronic conditions, such as diabetes, hypertension, and asthma.
Healthcare and/or managed care industry experience required.
Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written.
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
Typical office working environment with productivity and quality expectations.

Requires an RN with unrestricted active license

Education

RN with current unrestricted Virginia state or compact licensure.
Case Management Certification CCM preferred


Notes:
Schedule is Monday-Friday 8:00am – 5:00pm EST. No nights, no weekends, no holidays and no on-call.

safety sensitive

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status