Claims-CW - Care Manager, RN (Licensed)

Job Responsibilities:

• Function as a primary clinician for members with complex health needs with the depth of engagement ranging from basic coaching to intensive case management. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making.
• Conduct telephonic clinical assessments that address the health and wellness needs of the Organization's members using a broad set of clinical and motivational interviewing skills with the goal of effecting members’ self-management and positive behavior changes.
• Develop case or condition-specific plans of care using the clinical information system to establish short and long-term goals.
• Establish a plan for regular telephonic contact with each member to review progress and assess the potential for additional needs.
• Communicate with the member’s treating provider or providers in more complex clinical situations requiring case management intervention. Also serves as a subject matter expert to clinicians from other HMS teams to provide education, consultation, and training when indicated.
• Identify on-line, telephonic and community-based resources that can assist the member to achieve and maintain their personal health goals and assists the member to access those services.
• Proactively incorporate lifestyle improvement and prevention opportunities into member interactions and coaching.
• Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
• Other duties as assigned or requested, such as coordination of Blue Distinction Centers for Transplant Excellence for their services to ensure that members access these facilities whenever applicable.
• Senior Specialized Case Managers also work closely with Benefits Analysts to coordinate interpretation of benefit language and to ensure that all related services such as appeals/denials, provider inquiries, and claims processing are completed thoroughly and accurately.

Skills:

• 5+ years of relevant experience
• Must be a current licensed RN in the state of PA
• Disease Management knowledge or experience.
• Certified Case Manager preferred
• Prior experience working in case management and managed care
• Knowledge of assessments and care plans.
• Experience with community resources.
• Some knowledge of preventive health services.
• 1-800-line experience preferred.
• Experience working with the Medicaid population.
• Must have great work ethic.
• Able to work independently.
• Telephonic outreach to members.
• Excellent verbal and written communication skills

Education/Experience:

• Licensed RN in the state of PA
• Certified Case Manager