Job Description:

• Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care.
• Develop and document a case management care plan in direct collaboration with the beneficiary, the beneficiary's family or significant other(s), the primary physician and other health care providers. Identify and include key concerns, needs, and preferences of the beneficiary and family/caregiver.
• Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan.
• Coordinate and implement the activities specified in the care plan to provide optimal benefits coverage as well as promote continuity of care and integration of services for the beneficiary across care transitions. Collaborate and communicate with the beneficiary, family, significant other(s), physician, and other health care providers to accomplish the goals on the care plan.
• Monitor and continually evaluate the care plan on a scheduled basis to ensure it remains effective and to determine if desired outcomes are met and the goals are achieved. Revise and update the care plan as needed in collaboration with the beneficiary and the health care team.
• Initiate care conferences with Medical Director and/or the multidisciplinary care team to discuss challenging beneficiary cases and obtain expert clinical opinion or consultation.
• Serve as beneficiary advocate by promoting self-determination, informed and shared decision-making, autonomy, and self-advocacy for beneficiaries. Empower beneficiaries by providing education and support to reinforce self-care management, facilitate access to care, and promote optimal health outcomes.
• Identify relevant benefit-related, educational, and health care resources for beneficiaries. Facilitate coordination of care with existing community-based programs and services to meet the identified needs of the beneficiary.
• Demonstrate and apply knowledge of the philosophy/principles of comprehensive case management, patient-centered, culturally sensitive care coordination, and management of complex conditions throughout the case management process.
• Collaborate with beneficiaries and their support system/caregivers, providers, the multi-disciplinary team, and health care and community resources throughout the case management process.
• Be familiar with and understand the scope of professional licensure and carry out case management activities consistent with the scope of this licensure.
• Participate in ongoing training and professional development to build and maintain case management competencies, including evidence-based practices that promote positive health outcomes and cost-effective care.
• Maintain CEUs as required by applicable State Board(s) of Nursing and required certifications. Must be willing to obtain and maintain additional licenses as required to meet business needs.
• Conduct case management activities consistently with professional standards of practice as well as all applicable policies and procedures.
• Participate in regular team conferences and meetings.
• Document appropriate clinical information and data in a timely, accurate, and concise manner consistent with applicable standards of practice.
• Maintain a working knowledge of and adhere to applicable federal and state regulations including, but not limited to, laws related to patient confidentiality, release of information, and HIPAA. Apply knowledge of privacy and security regulations in daily practice to ensure compliance.

Requirements:

• Current, unrestricted RN license in state of residence with multi-state privileges (an active compact state license)
• Must hold United States citizenship status
• Ability to obtain Security Clearance required. Current DOD Security Clearance preferred
• Associate or bachelor's degree in nursing from an accredited institution. Bachelor’s degree preferred
• 5+ years of clinical RN experience in direct patient care
• Knowledge of case management practices and patient-centered care concepts
• Proficiency in Microsoft Office, mobile technologies and navigating multiple applications
• Ability to adapt to changing priorities
• 1+ years of prior case management experience (preferred)
• Case Management Certification highly desirable (CCM preferred)
• Experience working in an NCQA accredited case management program (preferred)
• Experience as a telephonic case manager at a health plan highly desirable
• Excellent organizational and prioritization skills (preferred)
• Strong communication skills (verbal, written, presentation, interpersonal) (preferred)
• Ability to work independently and collaboratively (preferred)
• Critical thinking and clinical problem-solving skills (preferred)
• Appreciation for cultural diversity and health and digital