Nurse Case Manager

Nurse Case Manager

Richmond VA and surrounding area. Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively manage healthcare costs and improve healthcare program/operational efficiency involving clinical issues Facilitates optimal outcomes. Identifies and follow through with continuous quality/ compliance opportunities . Educates/ empowers members to ensure compliance, satisfaction and promote patient advocacy.

Duties

• Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to programs and plans.
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues.
• Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.
• Reviews prior claims to address potential impact on current case management and eligibility.
• Assessments include the member's level of work capacity and related restrictions/limitations.
• Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality.
• Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

Case management and/or discharge planning experience preferred

Position Summary

• Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness.
• Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration.
• Services strategies policies and programs are comprised of network management and clinical coverage policies.

Active RN license in Virginia required Associate or Bachelor's in nursing

RN, Case management