Complex Case Manager RN - (Remote)

Lensa; Lincoln (NE); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a dedicated Case Manager to oversee a diverse panel of members with varying health needs. This role emphasizes the importance of clinical judgment and data analytics to tailor interventions and improve patient outcomes. You will collaborate with a multi-disciplinary team, engage with members to create personalized care plans, and navigate barriers to care. If you're passionate about making a meaningful impact in healthcare and possess strong organizational and analytical skills, this opportunity is perfect for you. Join a dynamic team committed to enhancing the health and well-being of our community.

Qualifications

• 7+ years of clinical, case management, or health insurance experience required.
• RN license in PA, WV, DE, or NY required.

Responsibilities

• Manage a specified panel of members, assessing health management needs.
• Develop care plans and conduct outreach to improve health outcomes.

Skills

Written and verbal presentation skills

Negotiation skills

Analytic skills

Interpersonal skills

Organizational skills

Time management

Project management

Self-directed

Education

High School Diploma/GED

Bachelor's Degree in Nursing

Tools

MS Excel

Job description

This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizes data/analytics in conjunction with professional clinical judgment to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.

ESSENTIAL RESPONSIBILITIES

1. Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support.
2. For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment.
3. Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved.
4. Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
5. Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization.
6. Other duties as assigned or requested.

EDUCATION

Required

• High School Diploma/GED

Substitutions

• None

Preferred

• Bachelor's Degree in Nursing

EXPERIENCE

Required

• 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and/or health insurance experience

Preferred

• Disease Management / experience managing multiple chronic conditions
• Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT)
• Experience working with the healthcare needs of diverse populations
• Understanding of the importance of cultural competency in addressing targeted populations

LICENSES AND CERTIFICATIONS

Required

• RN license in PA or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment.

Preferred

• Certification in Case Management

SKILLS

• Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion
• Broad knowledge of disease processes
• Understanding of healthcare costs and the broader healthcare service delivery system
• Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data
• Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
• Ability to work in a high performing team environment that requires flexibility
• Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills
• Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy

LANGUAGE REQUIREMENT (Other than English)

None

TRAVEL REQUIREMENT

0% - 25%

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS

Position Type

Office-Based

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.