RN Care Manager

Arizona Priority Care; Chandler (AZ); Hybrid; USD 61,992 - 64,747; Full time

Job summary

Arizona Priority Care in Chandler, AZ is seeking a registered nurse to join our care-management team. The RN Care Manager will support Medicare Advantage members through telephonic and in-home outreach, coordinate transitions of care, and collaborate with the interdisciplinary team to ensure high-quality outcomes.

Required is an AZ nursing license with BSN preferred and at least five years in acute care or care management.

Qualifications

• Current, unrestricted AZ Nursing license required; BSN RN preferred.
• Knowledge of Medicare and state managed care regulations; prior managed care experience preferred.
• 5 years acute care or care management experience; ER/Tele/ICE or other clinical role experience preferred.
• Ability to present clinical information accurately and confidently.
• Reliable transportation with valid driver's license, current auto insurance, and clean driving record.
• Excellent communication and professional demeanor with all levels of staff and external customers.
• Ability to work independently and as part of a team with minimal supervision.
• Experience navigating Electronic Health Records Systems.

Responsibilities

• Participates in outreach to MA members for Telephonic Care Management, including in-home visits when indicated.
• Performs ED follow-up calls.
• Facilitates member/family/caregiver education through referrals to CCM, Palliative Care, Telephonic Care Management, and Hospice as appropriate.
• Identifies psychosocial needs and facilitates referrals to social work or behavioral health.
• Documents changes in member condition in qHMO as they occur.
• Completes initial hospital admission review with AZPC Medical Directors for medical necessity determinations.
• Reviews status changes and collaborates for appropriate determinations.
• Writes rationales for reviews not meeting status requests.
• Reviews disputed PDRs with Medical Director for medical necessity determinations.
• Reviews SNF, ARC, and LTAC requests with Medical Director and informs hospital case manager.
• Assists SNF with discharge planning to ensure timely, safe discharges.
• Identifies and submits potential quality issues to Quality Department and utilization issues.
• Identifies and submits PQIs to Medical Director.
• Shares after-hours/weekend/holiday coverage for Care Coordination.
• Participates in Interdisciplinary Care Team.
• Maintains strong teamwork and willingness to adapt to change.
• Performs other duties as assigned.

Skills

Managed Care

Care Coordination

Acute/ED Care

Communication

EHR experience

Patient Assessment

Education

AZ Nursing License

BSN Preferred

Tools

EHR Systems

Job description

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 14 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

In the role of a RN Care Manager, you will leverage your core skills in managed care, patient service, and nursing to provide high-quality care and support to patients. Your premium skills in Acute care experience will enable you to excel in handling complex medical cases and emergencies effectively. With relevant skills in inpatient and outpatient care, you will collaborate with healthcare teams to ensure seamless transitions and continuity of care. Utilize your expertise in patient assessment, medical terminology, and discharge planning to make a meaningful impact on patient outcomes and healthcare delivery.

Position Duties & Responsibilities

• Participates in outreach to Medicare Advantage (MA) members for the Telephonic Care Management Program, including in-home, facility or community visits for members when clinically indicated and in support of Complex Care Management goals.
• Performs ED follow-up calls.
• Facilitates member/family/caregiver education through referrals to Complex Case Management (CCM), Palliative Care (PC), and Telephonic Care Management, and Hospice as appropriate.
• Identifies any psychosocial needs of the member and facilitates referrals to social work and/or behavioral health, as necessary.
• Documents relevant changes in qHMO of member’s condition or status, as they occur.
• Completes the initial hospital admission review, and collaborates with AZPC Medical Directors, for medical necessity determination for in-network hospitalized members.
• Performs re-reviews on all status changes, and collaborates with the Medical Director for appropriate status determination.
• Writes appropriate rationales on all reviews that do not meet status requests.
• Performs re-reviews on all disputed Provider Dispute Resolutions (PDR’s), and collaborates with the Medical Director for medical necessity determinations.
• Reviews Skilled Nursing Facility, Acute Rehab and Long-Term Acute Care requests for appropriate disposition with the Medical Director, and informs the hospital case manager of decision.
• Assists the Skilled Nursing Facility with discharge planning to ensure timely and safe discharges.
• Identifies and submits to the Quality Department any potential quality issues for review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
• Identifies and submits Potential Quality Incidents (PQIs) to the Medical Director.
• Equally shares in after-hours, weekend rotation and Holiday coverage for Care Coordination Department.
• Participates in Interdisciplinary Care Team.
• Strong teamwork philosophy and willingness to accept change proactively.
• Other duties as assigned.

Education, Training and Experience

• Current, unrestricted AZ Nursing license required. – BSN RN preferred.
• Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
• 5 years acute care of care management experience. Medical, ER, Tele, ICE or other relevant clinical role requiring quick critical thinking experience preferred.
• Must have the ability to present clinical information both accurately and confidently.
• Reliable personal transportation with valid driver’s license, current auto insurance, and acceptable driving record required.
• Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
• Ability to be detail-oriented, able to function under pressure and able to prioritize and re-prioritize tasks as needed.
• Ability to work both independently and as part of a team, with minimal supervision.
• Excellent customer service and communication skills, both oral and written.
• Ability to navigate numerous Electronic Health Records Systems.

*This role requires 60 days FT in office presence, hybrid options will be available after the 60-day period.*

Compensation range: The hourly range for this position is: $45 – $47