Case Manager Nurse - RN

2w2 weeks ago

Personify Health

US · Full-time · $72,000 – $74,000

About this role

As a Case Manager RN, you will provide telephonic case management between providers, patients and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants. May be required to work evening and/or weekend shifts.

You will contact patients and complete thorough assessments including physical, psychosocial, emotional, spiritual, environmental, and financial needs. Using claims processing tools, you will review paid claim data to develop a clinical picture and identify participation in appropriate programs.

You will develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary healthcare providers. You will monitor interventions, evaluate effectiveness, and report measurable outcomes while advocating for patients to facilitate quality care and reduce costs.

You will serve as a mentor to LVNs and provide guidance on complicated cases. This role offers the opportunity to impact health outcomes through personalized care navigation and cost management strategies.

Requirements

Knowledge of medical claims and ICD-10, CPT, HCPCS coding.
Ability to critically evaluate claims data and determine treatment plan, discharge planning experience.
Ability to work independently making decisions and problem solving.
Knowledge of community resources and alternate funding programs.
Computer proficiency or working knowledge of Microsoft Office Suite.
Excellent interpersonal, communication and negotiation skills.
Strong customer orientation.
Good time management skills.

Responsibilities

Contact patient and complete a thorough assessment including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
Develop treatment plan for standard and catastrophic cases in collaboration with patient, caregivers, family, community resources and multi-disciplinary healthcare providers.
Monitor interventions and evaluate the effectiveness of the treatment plan; report measurable outcomes that record effectiveness of interventions.
Initiate and maintain contact with patient/family, provider, employer, and multidisciplinary team as needed throughout the continuum of care.
Advocate for patient by facilitating quality care and reducing overall costs; provide patient/family with emotional support and guidance.
Negotiate and implement cost management strategies to affect quality outcomes and reflect data in monthly case management reviews and cost avoidance reports.
Maintain complete and detailed documentation of case managed patients in Eldorado and UM Web; ensure confidentiality according to Company policy and HIPAA.
Serve as mentor to LVNs and provide guidance on complicated cases as it relates to clinical issues.