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Summary:
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The Care Manager is a Registered Nurse who provides patient-centric holistic clinical assessments, case management, care coordination, authorization of medically necessary services, physical health/behavioral health disease education and outreach services to community-based organization to enhance the clinical support team
Essential Duties and Responsibilities:
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Maintains and ensures the confidentiality of all information collected during the review process
Serves as a member advocate providing support, triage and resolution of member issues
Serves as a facilitator to providers for resolution or provider concerns, complaints and grievances.
Participates in developmental and quality training programs
Communicates program parameters with providers and members
Identifies individual care needs based upon assessment outcomes
Establishes care needs, goals and interventions based on patient-centric holistic care requirements
Establishes and updates care plans based on departmental policies and procedures
Communicates with physicians, patients and family members regarding care plans, goals and expected outcomes
Monitors clinical and functional status based on goals and outcomes
Maintains appropriate level of experience and/or education to oversee care for specialty populations
Instructs patients telephonically in Disease Management Programs
Analyzes medical and pharmaceutical claims data .
To facilitate authorization/approval of medically necessary services in accordance with program requirements
To communicate with physician, patient, family and other health care providers, service authorizations, care plans, goals and expected outcomes.
To monitor clinical, functional and utilization status based on goals and outcomes.
To be able to effectively assess disease knowledge, teach the disease specific content of the chronic disease and health education programs to members and/or responsible parties via telephone communication.
Other duties as assigned.
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Other Responsibilities:
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Adheres to the policies and procedures ofÂCommunity Health Solutions of America, Inc.
Adheres to URAC HUM, Case Management and Core accreditation standards
Maintains strict confidentiality of client, company and personnel information
Demonstrates a strong commitment to the mission and values of the organization
Adheres to company attendance standards
Performs other duties as assigned
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Supervisory Responsibilities:ÂÂ None
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Competencies:
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Strong organizational and interpersonal skills
Excellent written and verbal communication skills
Detail oriented
Ability to multi-task and work independently
Excellent customer service skills
Qualifications:
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A minimum of three (3) years of Case Management or Disease Management experience is strongly preferred
Demonstrated knowledge of utilization management principles
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Education and/or Experience:
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A Bachelors degree in a health related field is strongly preferred.
Current RN Compact State License is required with MI, AL, OR, and KS current state licenses preferred; or, current RN licensure in Florida and other states were business is conducted (MI, AL, OR, KS, LA, AZ, CO, GA, ID, IA, KY, SC, TN, TX) is required.
CCM certification is preferred
Health Coaching experience is preferred
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Certificates, Licenses, Registrations:
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Certified Case Management (CCM) Certification is required within three (3) years of employment. Other certifications recognized by URAC are also acceptable.
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Computer Skills:
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Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook. Ability to type care coordination documentation directly into the system.
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Environmental Factors/Physical Demands:
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Work is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.
