Complex Care Manager (RN)

Job Purpose

The Complex Care Manager (RN) position involves a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual''s health needs through communication and available resources to promote quality cost-effective outcomes. This position utilizes an interdisciplinary team approach in developing care plans for members, tracks and trends major complex case management benchmarks, and provides patient education in an effort to reduce ER and Hospital Utilization. In addition, this position will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values.

Culture and Values Expectations

At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission "to deliver quality and compassionate care with outstanding service, every patient, every time". As a Complex Care Manager (RN) HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.

• Integrity: Do the right thing, the right way, every time.

• Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.

• Compassion: Treat everyone with respect and dignity.

• Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.

• Synergy: Collaborate to improve outcomes.

• Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.

• Stewardship: Use resources responsibly and efficiently.

• Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.

Essential Job Duties & Responsibilities

• Coordinate care needed by members with highly complicated, complex, or catastrophic medical conditions, and in conjunction with the interdisciplinary team, the CCM develops a care plan for meeting those needs in the most cost effective way possible while insuring quality is met working within the parameters of available benefits.
• Facilitate access to medically necessary services and ensure that they are provided at the appropriate level of care in a timely manner acting as a liaison between members and all providers to enhance communication and coordination of care.
• Provide consistent reporting to Medical Director (s) and management presenting clinical information on current cases, identifying potential cases for ongoing case management and service review, and coordinating care with other Medical Management team members.
• Develop a plan of care to include long and short term SMART goals based on problems identified, interventions aimed at assisting the member to meet their goals, education regarding specific care need, assistance to members in reducing barriers in order to maximize positive member outcomes, and evaluation of member's progress through plan of care implemented.
• Develop follow-up mechanisms for outstanding or unresolved requests to ensure that timely care is provided.
• Maintain current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms.
• Active participation in Quality Improvement through such activities as occurrence reporting, special projects, grievance review, program evaluation, etc.
• Assist in documenting policies and procedures for training and replication.
• Nurture effective working relations with physicians and staff so they will call on managed care staff as a resource and seek assistance with specific patients.
• Monitor productivity and provide constructive feedback when opportunities for improvement are identified.
• Set goals for performance and deadlines in ways that comply with company's plans and vision.
• Comply with all guidelines established by the Centers for Medicare and Medicaid (CMS), if applicable.
• Other duties may be assigned.

Experience

• 5 years strong clinical background.
• Prior HMO/Managed Care experience or equivalent experience preferred.
• Prior Care Plan development
• CCM a Plus
• Strong computer skills, including MS Word and Excel
• Strong oral and written communication
• Strong interpersonal and organizational skills
• Experience with an Electronic Medical Record and documentation programs.

Education

• Graduate of an accredited nursing school of nursing, BSN preferred.
• Current RN TX licensure required.

Knowledge, Skills & Abilities

• Experience in Care Plan development
• Experience in telephonic assessments
• Case Management experience in either insurance or inpatient setting

Work Hours, Travel Requirements

• Monday - Friday, 8:00 a.m. - 5:00 p.m., and as needed to complete projects.
• Conversion to hybrid upon completion of training

Working Conditions & Physical Requirements

Ability to work well with clinical staff and provide quality patient care, every patient, every time. Able to effectively communicate with all others respectfully regardless of racial, ethnic or economic status. Demonstrate knowledge of electronic medical records skills and able to prioritize tasks and organize work flow.

• Requires prolonged sitting, some bending, stooping and stretching and occasional lifting up to 50 pounds.
• Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.
• Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports.
• Normal office environment.

Please note this job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities that are required of the employee for this job. Job responsibilities, location, work hours, etc., may change at any time with or without notice.