Responsible for working with members, providers, and other multidisciplinary team members to facilitate, collaborate and coordinate healthcare for members identified with complex healthcare needs. Work with members throughout the continuum of care to enhance the members healthcare experience and assist with the provision of cost-effective healthcare options.
KEY RESPONSIBILITIES:
Complete clinical assessments of members requiring case management oversite to assist with facilitation of authorizations regarding healthcare benefits.
Collaborate with PCP offices to assure all medical needs and barriers are being addressed.
Conduct reviews to encourage patient engagement regarding healthcare needs and establish member goals for their health.
Perform telephonic or face to face case reviews with the Medical Director as needed.
Perform ongoing monitoring of the members benefits and health status to assess for cost effective opportunities to impact care and care alternatives if appropriate.
Maintain member outreach to meet regulatory requirements of CMS and URAC, as well as health industry standards.
Accurately document case interactions with other healthcare providers and team members.
Responsible for completing case management research, logs, and data entry for operational and reinsurance purposes.
Perform other job-related duties as assigned.
QUALIFICATIONS:
Ability to assess situation, consider alternatives and choose the appropriate course of action.
Ability to reason logically and to use good judgment when interpreting materials or situations.
Knowledge of managed care and associated group benefit plans.
Possess strong oral and written communication skills.
Proficient with Microsoft applications.
Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:
Graduation from an accredited School of Nursing.
Current, active, unrestricted license to practice as Registered Nurse (RN) in the State of Oklahoma.
At least 3 years of clinical nursing experience required.
Some experience in an acute care setting required for positions involved with concurrent review of acute care
Previous discharge planning, care coordination or case-management experience preferred.
CCM certification preferred.
CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin