Nurse Case Manager (Medical/Surgical)

Under the direction of the Case Management Supervisor, the Nurse Case Manager is responsible for providing telephonic case management services to MedCost customers. This position will work with the health care provider staff, via telephone, fax, and e-mail, in the coordination of care for members ranging from low acuity to catastrophic as they move through the care continuum. The Nurse Case Manager shall practice solely within the scope of a licensed registered nurse and individual competency and education for this position. The role requires experience providing direct patient care.

Confirm eligibility and policy provisions. Obtain consent for case management services and communicates case management objectives to the patient and their primary caregiver/support system and determine patient and family desires. Gather clinical information to assess and initiate discharge planning from hospital admittance to discharge. Collaborate and communicate with the member's health care team to coordinate the care needs for the member. Review available resources of all providers to determine the means of providing the highest quality care in the most effective setting. Obtain an estimate of the patient's current costs from the provider or other sources and compare to those of the alternative means of providing the necessary care. Provide ongoing education to members regarding their health care needs, available benefits and services. Identify barriers to optimal care and outcomes or clinical concerns and communicate with member and providers to formulate action plan to address Work to facilitate member compliance with their care/treatment plan and to ensure continuity of care. Maintain detailed records of all care coordination activities and interventions in the member's health plan clinical record. Notify appropriate persons in writing or by telephone of any potentially high dollar claim and the projected continued costs. Monitor alternative services for effectiveness, continued medical necessity and coverage. Advise all concerned parties when coverage may no longer be available due to cessation of medical necessity or benefit exhaustion. Facilitate patient referrals to community-based funding resources. Evaluate the effectiveness of the case management process.