Job Description

Job Description

Responsible for health care management and coordination within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. The Complex Case Manager will connect with the members on the phone to implement and tailor care plans according to the member’s needs. Along with other members of the health team, conduct comprehensive assessments that include the medical, behavioral, pharmaceutical and social needs of the patient, identify gaps in care and barriers to attaining improved health. Based on this assessment, and in conjunction with the member, the member’s physician and other members of the health team, create and implement a care plan that will address the identified needs, remove the barriers and improve the health of the member.

ESSENTIAL JOB FUNCTIONS:

1. Coordinate care by serving as a resource for the member with complex health needs, their family and their physician.
2. Conduct health risk assessments with members via phone to address the health and wellness needs of members.
3. Develop individualized care plans on members specific needs that account for physical, psychosocial and other constraints.
4. Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual patients and the population served.
5. Ensure access to appropriate care for members with urgent or immediate needs facilitating referrals/authorizations within the benefit structure as appropriate.
6. Assesses the member's current health status, resource utilization, past and present treatment plan and services; prognosis, short and long term goals, treatment and provider options.
7. Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
8. Conducts and participates in IDT meetings.
9. Interfaces with Primary Care Physicians, Nurse Practitioners and specialists on the development of care management treatment plans.

EDUCATION/EXPERIENCE:

• 2+ years of nursing experience in an acute care hospital setting
• 1+ years of managed care and utilization review experience

Experience with clinical review

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