Transplant Case Manager, RN

Imagine360 is an integrated health plan addressing one of the greatest challenges on behalf of self-funded employers: healthcare costs are harming the bottom line, they're increasingly unaffordable for employees, and the experience remains poor. We help businesses and their employees navigate through clutter and chaos and bring deep cost savings that protect everyone’s well-being and budgets. It’s way more than a health plan. It’s a promise. We’ve helped hundreds of self-funded clients. Our solutions are ready to be implemented. The results are proven and impactful. Imagine360’s innovative payment model includes preferential contracting with providers and health systems, and additional price protection through reference-based pricing, saving employers 15-30% on average compared to the national carriers. With more than 17 years’ experience, and 25-million-months of member data, Imagine360 offers care coordination and medical management to proactively guide members through the complexities of healthcare. We bring employers a reimagined health plan solution, created to provide the flexibility, service and support employers need to take good care of employees, their families and business. We do this through: Assistance with plan design and expert administration with integrated third-party administration Built-in price protection from the #1 reference-based pricing solution in healthcare Provider contracts with Imagine Health’s top-rated providers and health systems Comprehensive member support throughout their healthcare journey It’s more than a health plan. It’s our promise to deliver a better health plan experience.

Imagine360 is seeking a Transplant Case Manager, RN to join the team! The Transplant Case Manager, RN is responsible to providing case management for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical and professional experience. The Registered Nurse will practice within the scope of nursing practice while performing assessments, coordinating care, planning, monitoring, evaluating and determining outcomes. Position Location: 100% remote

Identify, collect, process, and manage data to perform the Case Management process by utilization Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures Completes clinical assessments per P&P to identify and deliver indicated medical service coordination. Manage the transplant cases, cases that may lead toward organ transplant, and complex disease cases. Utilize clinical knowledge, expertise, and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment. Assess the need for and collaborate with community resources for members in case management. Uses assigned software accurately to document to complete and document all steps of review of medical necessity and case management process, including time slips. Facilitate the Patient Satisfaction Surveys Assess for cost savings and document the cost saving in assigned software Appropriately refer complex cases to Supervisor, Case Management, or designee Performs essential activities of case management while maintaining members' confidentiality, safety, advocacy, adherence to ethical, legal and accreditation and regulatory standards. Performs assessments of each member to identify CM needs. Consistently exercises discretion and judgment to analyze, interpret, make deductions, and then decide what actions are necessary based on the varying facts and circumstances of each individual case. Determines measurable goals utilizing motivational interviewing and behavior change model and coaches' clients while monitoring self-care practices. Utilizes industry standard tools to guide individuals with chronic/ongoing health conditions through coaching, assessments, listening, and other techniques as appropriate. Executes activities or interventions to achieve the goals in the plan. Organizes, integrates, and modifies the resources needed to reach the goals in the plan. Monitors all information from all relevant sources in the plan and its activities and services to determine the plan's effectiveness. At repeated intervals, evaluates to determine ultimate effectiveness of plan and modifies plan appropriately to meet the goals. Research medical procedures, treatments, and coding when necessary. Measures the outcomes of interventions. Adheres to practicing the care management core components throughout the continuum of care: Case Management Concepts Case Management Principles and Strategies Psychosocial and Support Systems Healthcare Management and Delivery Healthcare Reimbursement Vocational Concepts and Strategies. Customer Service Acts as a role model in demonstrating the core values in customer service delivery. Provides timely and thorough follow up with, internal and external customers. Appropriately escalates difficult issues up the chain of command. Quality Assurance Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction. Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters. Performs self-quality monitoring to develop and execute plans to meet established goals. Provides ongoing feedback to help optimize quality performance. Collaborates with others and cross-departmentally to improve or streamline procedures. Develops new or improves current internal processes to improve quality. Attend and participate in team meetings, trainings, and other job specific events as required. Communicates (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives and stop loss as needed. Communicates professionally and effectively. Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and Procedures. Participate in the Quality Management Program via collecting and adhering to performance metrics per Case Management Policy Complete HIPAA Training Annually. Perform all tasks in accordance with HIPAA/PHI guidelines. Appropriately escalate difficult issues. Complete duties in accordance with scope of licensure and certifications held or requested. Perform other duties and projects, as assigned. Areas of Responsibility Scope of Practice: In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making and patient education. The scope of practice includes, but is not limited to: Evaluating clinical data Assessment and evaluation of the acquired clinical date to assess for appropriateness of treatment based on Imagine360 clinical guidelines, Coordination of treatment plans, interventions, and outcome measurement Rationale for the effects of medication and treatments Provide patient education and educational resources. Accurately report: Administration of medication and treatments Client response Contact with other health care team members. Respect the client's right to privacy by protecting confidential information. Promote and participate in education and counseling to a participant based on health needs. Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner. The Transplant Case Manager will have knowledge and practice the core components of Case Management that include: Case Management Concepts Principles of Practice HealthCare Management & Delivery Healthcare Reimbursement Psychosocial Aspects of Care Rehabilitation Professional Development & Advancement Quality and Outcomes Evaluation and Measurement Ethical, Legal and Practice Standards