This job works directly with providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted in relation to quality and care costs. The incumbent could work in a physician’s office, visit physician practices on a routine basis, work within a hospital setting and/or visit the member’s home. This job directly helps members with the highest risk scores to coordinate care and navigate the healthcare system by recommending and/or implementing interventions related to the improvement of medical care and costs.
- Conduct member-facing clinical assessments that address the health and wellness needs of the members with the highest risk scores using a broad set of clinical and motivational interviewing skills with the goal of impacting members’ self-management skills and positive behavior changes which will ultimately positively impact member satisfaction and care costs.
- Serve as a subject matter expert to both internal and external sources (e.g. members, providers, regulatory agencies, UM and policy) to provide education, consultation, and training.
- Serve as a resource to guide, mentor, and counsel others in regard to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources.
- Collaborate, coordinate, and communicate with the member’s treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention.
- Develop and implement case-or condition-specific plans of care and/or intervention plans, as needed, that can become a part of the member’s medical record to establish short and long-term goals.
- Establish a plan for regular contact (face-to-face as often as possible) with each member and/or provider to monitor progress toward goals, provide additional education and evaluate the need for modification or change in the plan of care.
- Proactively incorporate lifestyle improvement opportunities and preventive care into member interactions and coaching
- Collaborate with the appropriate individuals to offer solutions to refine and improve existing practices or participates in developing performance improvement processes that will enhance member outcomes and operational performance/excellence as well support all strategic initiatives including Health Care Reform and STARS initiatives.
- Work with providers related to performance measures and activities to educate and influence the behavior of members and providers.
- Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
- Other duties as assigned.
- Registered Nurse
- 5 - 7 years of Case Management Experience or 5 - 7 years of Clinical Practice Experience or 5 - 7 years of Disease/Condition Management Experience
- Bachelor's Degree in Nursing
- ACM Certification (Accredited Case Manager)
- Certified Chronic Care Manager (CCM)
- Microsoft Excel
- Communication Skills
- Self Starter
- Health Education
- Healthcare Industry
- Friendly Personality
- Data Analysis
- Statistical Analysis
Referral Level: 1
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