Nurse Case Manager

Serve as a team member on a multidisciplinary team, coordinating care, resources and/or services for members to achieve optimal clinical and resource outcomes.

Utilize applicable clinical skillset and perform comprehensive assessments to determine how to best collaborate with members, family, internal partners and external services/providers on plans for treatment, appropriate intervention and/or discharge planning. Develop a member-centric plan tailored to members’ needs, health status, educational status and level of support needs; identify barriers to meeting goals or plan of care Utilize community resources and funding sources as needed in the development of the plan of care. Perform ongoing monitoring and management of member which may include scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity. Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care, etc). Educate members and encourage pro-active intervention to limit expense and encourage positive outcomes Effectively document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome. May outreach directly to members identified as high risk, high cost, or high utilization cases. May review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible. May evaluate medical necessity and appropriateness of services as defined by department. As needed, develop relevant policies/procedures, education or training for use both internally and externally.