Claims-CW - Care Manager, RN (Licensed)

SGS Consulting; Elm (PA); Sur place; USD 85 000 - 120 000; Plein temps

Résumé du poste

SGS Consulting seeks an experienced Registered Nurse licensed in Pennsylvania to lead clinical care for members with complex health needs, providing coaching and intensive case management via telephonic contact.

You will develop care plans, coordinate with treating providers, connect members with community resources, and ensure documentation meets regulatory standards while supporting transitions and benefit navigation.

Qualifications

• Licensed RN in PA
• Certified Case Manager
• 5+ years of relevant experience
• Disease management knowledge or experience
• Prior experience in case management and managed care
• Knowledge of assessments and care plans
• Experience with community resources
• Knowledge of preventive health services
• 1-800-line experience preferred
• Experience with Medicaid populations
• Able to work independently
• Telephonic outreach to members
• Excellent verbal and written communication skills

Responsabilités

• Function as primary clinician for members with complex health needs and support self-management and navigation of health care.
• Conduct telephonic clinical assessments addressing health and wellness needs to effect self-management and positive behavior changes.
• Develop plans of care using clinical information systems to establish short- and long-term goals.
• Establish regular telephonic contact with members to review progress and assess additional needs.
• Communicate with treating providers in complex cases; educate and train clinicians as needed.
• Identify online, telephonic and community resources to help members achieve health goals.
• Incorporate lifestyle improvement and prevention opportunities into member interactions and coaching.
• Ensure all activities are documented and compliant with regulatory and accreditation standards.
• Coordinate with Blue Distinction Centers for Transplant Excellence when applicable.
• Collaborate with Benefits Analysts to interpret benefits language and manage appeals/denials and claims processing.

Connaissances

RN license PA

Case management

Disease management

Certified Case Manager

Managed care

Assessments

Resource coordination

Telephonic outreach

Medicaid experience

Independent worker

Verbal/written communication

Formation

PA RN license

Certified Case Manager

Description du poste

Job Responsibilities:

• Function as a primary clinician for members with complex health needs with the depth of engagement ranging from basic coaching to intensive case management. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making.
• Conduct telephonic clinical assessments that address the health and wellness needs of the Organization's members using a broad set of clinical and motivational interviewing skills with the goal of effecting members’ self-management and positive behavior changes.
• Develop case or condition-specific plans of care using the clinical information system to establish short and long-term goals.
• Establish a plan for regular telephonic contact with each member to review progress and assess the potential for additional needs.
• Communicate with the member’s treating provider or providers in more complex clinical situations requiring case management intervention. Also serves as a subject matter expert to clinicians from other HMS teams to provide education, consultation, and training when indicated.
• Identify on-line, telephonic and community-based resources that can assist the member to achieve and maintain their personal health goals and assists the member to access those services.
• Proactively incorporate lifestyle improvement and prevention opportunities into member interactions and coaching.
• Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
• Other duties as assigned or requested, such as coordination of Blue Distinction Centers for Transplant Excellence for their services to ensure that members access these facilities whenever applicable.
• Senior Specialized Case Managers also work closely with Benefits Analysts to coordinate interpretation of benefit language and to ensure that all related services such as appeals/denials, provider inquiries, and claims processing are completed thoroughly and accurately.

Skills:

• 5+ years of relevant experience
• Must be a current licensed RN in the state of PA
• Disease Management knowledge or experience.
• Certified Case Manager preferred
• Prior experience working in case management and managed care
• Knowledge of assessments and care plans.
• Experience with community resources.
• Some knowledge of preventive health services.
• 1-800-line experience preferred.
• Experience working with the Medicaid population.Must have great work ethic.
• Able to work independently.
• Telephonic outreach to members.
• Excellent verbal and written communication skills

Education/Experience:

• Licensed RN in the state of PA
• Certified Case Manager