RN Case Manager
Reports to: Department Manager
Department: Global Health Services
Calibrated Healthcare Network (CHN) manages over 11 million lives in over 8 states, partnering with industry leaders in the area of managed care. Our operating model features global workforce strategies, coupled with efficient technological solutions. We have a proven expertise in re-engineering complex managed care business processes to provide value to our esteemed partners. Our commitment to the evolution of healthcare is evident in our investment in research and development for the progression of dynamically enhanced technology to meet the needs of partners. The core suite of services includes Claims Adjudication, Benefits Setup, Member Enrollment and Eligibility Setup, Claims System Configuration, HCC Coding and MSO Development support.
The Calibrated Clinical Solution (CCS) global workplace is built on the concept of providing cost-effective care, enhancing population health strategies, and improving the quality of care. Calibrated Clinical Solutions deploys the use of proprietary software to create cost-effective workforce solutions constructed on the premise of collaboration technology. With our extensive domain of knowledge of managed care and dynamically enhanced technology, we have the capacity to create innovative solutions for our managed care and primary practice partners. Our core suite of services includes Medical Management, Utilization Management, Complex Case Management, and Population Health Management.
The RN Case Manager position is responsible for ensuring a collaborative process of assessment/problem identification, care plan development, facilitation of the care plan, care coordination, evaluation, and continuous monitoring of an assigned population of patients across care settings. The RN Case Manager is responsible for the advocacy of options and services to meet an individual’s and family’s comprehensive health needs to ensure quality care and cost-effective outcomes.
- Associates Degree in Nursing
- Bachelor of Science in Nursing preferred
- A current active Registered Nurse license issued by the California Board of Registered Nursing.
- Certified Case Manager (CCM) preferred
- Accredited Case Manager (ACM) preferred
- Certified Managed Care Nurse (CMCN) preferred
- Minimum 2 years clinical practice experience required, preferably in an acute care setting.
- Experience interpreting evidenced based guidelines (Interqual and/or Milliman criteria sets), health plan/client specific chronic care guidelines, and policies/procedures
- 1-year managed care experience preferred
- Previous case management experience preferred
- Core Competencies: Ethics and Values, Customer Focus, Action-Oriented, Learning on the Fly, Manage/Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
- Demonstrated ability to work together across professions and individuals to improve health outcomes.
- Computer Proficiency (MS Word, MS Excel, MS Outlook, Video Conferencing)
- Knowledge of NCQA, DMHC, and state requirements for case management
Essential Functions of Job
- Assessment: Evaluates and identifies an individual’s needs an intensity of case management services.
- Assessment: Performs data collection and analysis of the patient history to include, but not limited to, current medical status, demographics, nutritional assessment, medication assessment, financial assessment, environmental assessment, psychosocial assessment, cultural and religious assessment.
- Planning: Interfaces with the individual, individual’s family, primary care physicians, and specialists to develop the case management plan.
- Planning: Acts as a patient advocate and clinical liaison by identifying social needs and researching community resources available to meet patient’s needs.
- Planning: Appropriately activates members of the care team based on member assessment
- Planning: Develops individualized care plans focused on individual engagement, education, and self-management
- Planning: Able to align member’s identified assessment problems with individualized and prioritized interventions and SMART goals.
- Implementation: Implements a patient-centered interdisciplinary approach to carryout care plan
- Implementation: Act as facilitator and coordinates of care, services, resources, and health education specified in the planned interventions.
- Evaluation: Monitors and evaluates the effectiveness of the care plan and updates as necessary.
- Evaluation: Conducts ongoing follow-up with the individual, family and/or family caregiver in the evaluation of the individual’s status, goals, and outcomes
- Closure: Able to determine progression towards goals and appropriately move patients through the continuum of care