RN Case Manager, Inpatient Services - Remote from Texas
About the position Responsibilities • Collaborates effectively with integrated care team (ICT) to establish an individualized plan of care for members. • Serves as the clinical liaison with hospital, clinical and administrative staff, providing expertise for clinical authorizations for inpatient care. • Performs concurrent and retrospective onsite or telephonic clinical reviews at designated facilities. • Documents medical necessity and appropriate level of care utilizing nationally recognized clinical guidelines. • Interacts and effectively communicates with facility staff, members, and their families to assess discharge needs and formulate discharge plans. • Stratifies and validates patient level of risk and communicates during the transition process with the Integrated Care Team. • Provides assessments of physical, psycho-social, and transition needs in various settings. • Develops interventions and processes to assist members in meeting care goals. • Manages assigned case load efficiently, utilizing time management skills. • Provides constructive feedback to minimize problems and increase customer satisfaction. • Seeks ways to improve job efficiency and makes appropriate suggestions. • Demonstrates knowledge of utilization management and care coordination processes. • Confers with physician advisors regarding inpatient cases and participates in department case rounds. • Plans member transitions with providers, patients, and families. • Enters timely and accurate data into care management applications. • Adheres to organizational and departmental policies and procedures. • Takes on-call assignments as directed. • Attends and participates in integrated care team meetings. • Problem solves by gathering and reviewing facts to select the best solution. • Maintains current knowledge of health plan benefits and provider network. • Guides physicians in awareness of preferred contracts and providers. • Refers cases to Medical Director as appropriate. • Participates in the development of quality improvement processes. • Performs comprehensive assessments and documents findings in compliance with regulations. Requirements • Bachelor's degree in Nursing, or Associate's degree in Nursing and Bachelor's degree in related field, or Associate's degree in Nursing combined with 4+ years of experience. • Current, unrestricted RN license specific to the state of employment. • 2+ years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions. • 1+ years of managed care and/or case management experience. • Knowledge of utilization management, quality improvement, discharge planning, and cost management. • Proficient with Microsoft Office applications including Word, Excel, and PowerPoint. • Proven ability to read, analyze, and interpret information in medical records and health plan documents. • Proven ability to solve practical problems and deal with a variety of variables. • Proven planning, organizing, conflict resolution, negotiating, and interpersonal skills. • Proven independent problem identification/resolution and decision-making skills. • Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously. • Ability to maintain a valid and current driver's license. • Ability to frequently move or be in a stationary position for prolonged periods. Nice-to-haves • Case Management Certification (CCM). • Experience working with psychiatric and geriatric patient populations. • Bilingual (English/Spanish) language proficiency. Benefits • Flexible work options including remote work for Texas residents. • Opportunities for professional development and career advancement. • Supportive work environment focused on diversity and inclusion.