Description: Job Profile Summary:
Position Purpose:
Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families.
Education/Experience:
Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 4 years of related experience.
License/Certification:
RN - Registered Nurse - State Licensure and/or Compact State Licensure required
For YouthCare Illinois plan only: Bachelor s Degree and IL RN licensure required. Must reside in IL
For Sunshine Health (FL) Only: Employees supporting Florida's Children s Medical Services (CMS) must have a minimum of two years of pediatric experience. May require up to 80% local travel required
Responsibilities:
Evaluates the needs of the member, barriers to accessing the appropriate care, social determinants of health needs, focusing on what the member identifies as priority and recommends and/or facilitates the plan for the best outcome
Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs
Identifies problems/barriers to care and provide appropriate care management interventions
Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services
Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs
Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate
Facilitate care management and collaborate with appropriate providers or specialists to ensure member has timely access to needed care or services
May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators
Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits
Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner
Other duties or responsibilities as assigned by people leader to meet business needs
Performs other duties as assigned.
Complies with all policies and standards.
Custom Fields:
Name: Which Health Plan, programs or functions will this work support?
Value: Sunflower Health Plan
Name: If this request is replacing a previously canceled request, please provide the original Request ID
Value: None
Name: Shortlisting Date
Value: None
Name: Field Worker
Value: Yes