Nurse Case Manager II

MUST HAVE:

RN with current unrestricted state licensure in IL. REQUIRED

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. Requires an RN with unrestricted active license. Experience with case management and IL waiver services is preferred.

SAFETY

-Through the use of clinical tools and information/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

Position Summary:

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. Requires RN with unrestricted IL active license.

Duties:

Acts as a liaison with member/client /family, employer, provider(s), insurance
companies, and healthcare personnel as appropriate.
Implements and coordinates all case management activities relating to catastrophic cases
and chronically ill members/clients across the continuum of care that can include
consultant referrals, home care visits, the use of community resources, and alternative
levels of care.
Interacts with members/clients telephonically or in person. May be required to meet with
members/clients in their homes, worksites, or physician s office to provide ongoing case
management services.
Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or
vocational status; develops a plan of care to facilitate the member/client s appropriate
condition management to optimize wellness and medical outcomes, aid timely return to
work or optimal functioning, and determination of eligibility for benefits as appropriate.
Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.
Prepares all required documentation of case work activities as appropriate.
Interacts and consults with internal multidisciplinary team as indicated to help
member/client maximize best health outcomes.
May make outreach to treating physician or specialists concerning course of care and
treatment as appropriate.
Provides educational and prevention information for best medical outcomes.
Applies all laws and regulations that apply to the provision of rehabilitation services;
applies all special instructions required by individual insurance carriers and referral
sources.
Testifies as required to substantiate any relevant case work or reports.
Conducts an evaluation of members/clients needs and benefit plan eligibility and
facilitates integrative functions using clinical tools and information/data.
Utilizes case management processes in compliance with regulatory and company policies
and procedures.
Facilitates appropriate condition management, optimize overall wellness and medical
outcomes, appropriate and timely return to baseline, and optimal function or return to
work.
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/client s overall
wellness through integration.
Monitors member/client progress toward desired outcomes through assessment and
evaluation.

Experience:

Minimum 3-5 years clinical practical experience preference: (diabetes, CHF, CKD, postacute care, hospice, palliative care, cardiac) with Medicare members.
Minimum 2-3 years CM, discharge planning and/or home health care coordination
experience
Excellent analytical and problem-solving skills
Effective communications, organizational, and interpersonal skills.
Ability to work independently (may require working from home).
Proficiency with standard corporate software applications, including MS Word, Excel,
Outlook and PowerPoint, as well as some special proprietary applications.
Efficient and Effective computer skills including navigating multiple systems and
keyboarding

Education:

Registered Nurse with active state license in good standing within the region where job
duties are performed is required.
Associates degree with equivalent experience, applicant would be required to obtain a
bachelor s degree within 3-5 years as part of role development, state licensing laws may
apply
Certified Case Manager is preferred.