Utilization Management Nurse

Under the direction of the Director of Care Management, the RN Care Manager is responsible for managing high-risk, chronic illness members to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The RN Care Manager will formulate and implement a care management plan that addresses the members identified needs by assessing issues, resources, and care goals. The RN Care Manager will advocate for the member and support the member in navigating the health care system. Additionally, the RN Care Manager will work collaboratively with the interdisciplinary team and members PCP / Health Care Team to identify and support the achievement of the members short term and long-term health goals. HTA’s Care Management model is to provide longitudinal care management for identified members. Based on the RN’s work experience in nursing and knowledge of the health care system, the aims are to provide education and resources to members to ultimately reduce preventable emergency room visits and hospitalizations and re-admissions.

Collaborates with providers and practice staff in identifying appropriate members for care management, utilizing established Care Management criteria. Performs initial and periodic holistic assessments for identified care managed population. This includes physical and psychological concerns for members as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the member. Prioritize members according to intensity, need, and required to follow-up. Formulates and implements a care management plan that addresses the member’s identified needs by assessing the member/family needs, issues, resources, and care goals; determining the choices available to individual members; educating the patient/family on the choices available to meet their goals. Establishes a care management plan that is mutually agreed upon by the health care team and the member/family. Plans specific mutual self-management goals and objectives and interventions with the members that are action oriented. Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals. Monitors and evaluates the progress of the member at prescribed minimal intervals.