Your Role
The Case Management team performs and case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs.. The Case Management Nurse, Seniorwill report to the Manager, Care Management. In this role you will determine, develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of member inquiry, triage hub, chronic conditions, poly-pharmacy, and voluntary member health assessment, in addition to indication of multiple monthly ER visits. The RN in this role will be assisting members of the Catholic Diocese. The Care Management Nurse-Senior empowers members to take an active role in their healthcare by educating them on the benefits of their health plan, sharing resources, and providing high-quality options for care. Our nurses primarily work from home but travel expectations for in person meetings with clergy members up to a few trips per month that may be outside of California.Your WorkIn this role, you will:Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying withcontract for each appropriate plan typeProvide Referrals to QualityManagement (QM), Disease Management (DM) and Appeals and Grievance department (AGD)Recognize the client’s right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamDesign an appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomesInitiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settingsConducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.Assesses members’ health behaviors, cultural influences and clients belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers. Research opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.Planning: Designs an appropriate and fiscally responsible care plan with targeted interventions that enhance quality, access and cost-effective outcomes. Adjust plans or creates contingency plans as necessary.Assesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.Upholds professional, caring, and compassionate communication to both clients and vendorsResponds to client questions or concerns within 2 business days.Thorough documentation of interactions with vendors and clientsYour Knowledge and ExperienceRequires a current unrestricted CA RN License.Other assigned states are Oregon, Nevada, and Idaho. Must maintain active, unrestricted licensing in those states or the ability to obtain required licensure within 90 days of hire.Requires a valid California Driver’s License with Proof of InsuranceBachelor of Science in Nursing or advanced degree preferred.Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirementsRequires at least 5 years of prior experience in nursing, healthcare or related fieldAt least 3 years of managed care experience preferredDemonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.Extensive knowledge of evidence based clinical practice guidelines particularly for chronic conditions.Incorporates professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care.Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets preferred, Care GapsAble to operate PC-based software programs including proficiency in Microsoft Office 365 applications including Word, Excel, Outlook, PowerPoint and Teams.