Nurse Case Manager II

Our client, a Retail Pharmacy company, is looking for a Nurse Case Manager II for their Remote location.


Responsibilities:

• Conduct telephonic visits using comprehensive assessment tools for members enrolled in Managed Long Term Services and Supports (MLTSS).
• Perform in person assessments for non MLTSS members to determine medical needs and support appropriate service referrals (e.g., adult medical daycare, pediatric medical daycare, personal care assistant services, nursing facility custodial care, Personal Preference Program, and MLTSS enrollment).
• Work with diverse populations, including pediatric and medically complex members.
• Coordinate and collaborate with members, authorized representatives, primary care providers, and interdisciplinary care teams.
• Schedule and participate in interdisciplinary meetings, advocating for members to ensure safe transitions and appropriate services.
• Develop individualized care plans and authorize services within MLTSS/FIDE program benefits in a cost effective manner.
• Document all assessments, interactions, and care planning activities accurately and in a timely manner in the electronic health record.
• Utilize strong critical thinking and problem solving skills in daily work.
• Mentor new staff once appropriate proficiency has been achieved.
• The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.
• Through the use of clinical tools and data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services
• Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

• Minimum of 3 years of clinical experience in settings such as hospitals, home health, or ambulatory care.
• Must Be Fluent on English/Spanish (Writting, Reading, Speaking)
• Experience in case management and/or discharge planning
• Background in managed care
• Crisis intervention skills
• Verifiable High School Diploma or GED Required:
• 3 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
• Healthcare and/or managed care industry experience.
• Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
• Effective communication skills, both verbal and written.
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
• Sedentary work involves periods of sitting, talking, and listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer.
• Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.
• Typical office working environment with productivity and quality expectations
• Case Management Certification CCM preferred

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities