Case Manager Rn

100% REMOTE - can sit in any state but first preference is for NY, NJ, and PA

Shift: Various schedules from 8am ET to 9pm ET
 

Summary: The Health guide program is an innovative program that integrates clinical care, non-clinical concierge customer service, and data analytics into a seamless service for our clients. The clinical team focuses on addressing barriers to care and improving member outcomes through supportive, holistic, member centric care plans and interventions. While we focus on pre-admit, post-discharge and high utilization (hospitalizations and ER visits), our members can have some very complex needs and experience with managing members with chronic conditions, catastrophic illness, people with disabilities, member who are experiencing high risk maternity and neonatal intensive care is essential. While you do not have to have experience in managing all of the listed populations, being willing to learn is necessary.
The populations we manage can be any age, we support members across the lifespan, so feeling confident in working with members of any age is needed.
This team functions as an outbound clinical call center; it is a fast pace, and structured environment. Our nurses work on outbound dialer technology, this helps improve our outreach efforts, and reaching those members who need us most. The dialer manages calls through an automated process verses the nurse completing a manual dial. We also work with our internal departments to ensure we have the right number of nurses with the right skill to manage the membership. Managing our schedules and break times is done through a workforce management department, who is an integral partner to our success.
Responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers. Performs care management activities within the scope of licensure for members with complex and chronic care needs.
Primary duties may include, but are not limited to:

• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting and level of care.
• Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance.
• Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.
• Conducts clinical assessment to develop goals that address individual needs in order to develop a care plan; implements and coordinates a care plan.
• Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
• Assists with development of utilization/care management policies and procedures.
• Participates in or leads intradepartmental teams, projects, and initiatives.

Minimum Qualifications:

• Clear and Active RN license
• 3 years case management experience
• Prior managed care experience
• Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
• Certified Case Manager (CCM) preferred
• COVID Vaccine not required but preferred if a candidate is interested in possibly converting perm with Elevance, it is required for all FTEs