RN Case Manager

• Coordinates the care and services of Long Term Care members across the continuum of illness. Promotes effective utilization and monitors health care resources. Assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes. Works with the PCP member?s family Supervisor/Manager of Care Management to assess plan implement coordinate monitor and evaluate services and outcomes to maximize the health of the Member.

• In conjunction with the PCP member member?s family and other pertinent members of the Interdisciplinary Care Team (IDT) CM completes a comprehensive assessment and develops a Person Centered Service Care Plan utilizing clinical expertise to evaluate the member?s need for alternative services. Assesses short-term and long-term needs and establishes case management objectives

• Manages 75 to 100 active cases based on case intensity and acuity

• Responsible for Utilization Management and uses prescribed criteria to provide timely appropriate and medically necessary service authorizations

• Interacts continuously with member family physician(s) IDT members and other providers utilizing clinical knowledge and expertise to determine medical history and current status. Assesses the options for care including use of benefits and community resources in order to update the Person Centered Service Care Plan

• Acts as liaison and member advocate between the member/family physician and facilities/agencies

• Maintains accurate records of care management activities in the EMMA system using clinical guidelines

• Coordinates community resources with emphasis on medical behavioral and social services. Applies care management standards and maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues

• Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.

• Participates in monthly chart audits

• Performs special projects as assigned.