Claims-CW - Care Manager, RN (Licensed)

SGS Consulting; Philadelphia (Philadelphia County); On-site; USD 70,000 - 90,000; Full time

Job summary

SGS Consulting is seeking an experienced RN in Pennsylvania to serve as a primary clinician for members with complex health needs, delivering coaching, case management and care coordination with treating providers.

You will conduct telephonic assessments, develop short- and long-term care plans, and maintain regular contact to review progress and adjust plans as needed, while ensuring compliance with regulatory standards and patient-centered care.

Qualifications

• 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

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

RN licensed PA

Disease Management

Certified Case Manager

Managed care experience

Assessments and care plans

Community resources

Preventive health

1-800-line experience

Medicaid population

Independent work

Telephonic outreach

Verbal & written communication

Education

RN license PA

Certified Case Manager

Job description

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