Ensures member access to services appropriate to their health needs
Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
Coordinates internal and external resources to meet identified needs
Monitors and evaluates effectiveness of the care management plan and modifies as necessary
Assists in problem solving with providers, claims or service issues
Coordinate referrals to local and statewide resources including behavioral health, housing, transportation, and food assistance
Partner with community health organizations, advocacy groups, and outreach teams to strengthen member connections
Plan, coordinate, and deliver educational events in collaboration with community partners, employers, or local health organizations
Provide group-based and one-on-one education on chronic conditions, medication adherence, preventive screenings, nutrition, and self-care
Support initiatives that address health equity and promote culturally responsive care
Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups
May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff
Participates in department audit activities
Requirements
Requires BA/BS in a health-related field and minimum of 5 years of clinical experience
Current, unrestricted RN license in applicable state(s) required
Nursing experience in Home Health, Managed Care, Case Management, or Care Coordination preferred
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