Care Management Nurse RN (Houston Texas)

JOB SUMMARY
Care Manager will manage Community Health Choice (Community) members with chronic disease and medically complicated needs through comprehensive evaluation and through coordination of Community resources. The Care Manager will participate as a team member in Community Care Management programs, which are designed to assist members with chronic diseases in self-management skills. Care Manager will work collaboratively with utilization review, member services and the quality improvement department.

JOB SPECIFICATIONS AND CORE COMPETENCIES

30% Caseload Management- Documents case status and reviews dates accurately in
care management module. Caseload activities completed timely per review dates
assigned or within authorization time frame turnaround time requirements.
Initiates/receives member calls related to Program need for assessments and follow up contacts. Available as clinical oversight and resource for the LVN Care
Management Specialist. 

20% Initial Intervention- Identification and contact potential members for any of the Care Management Programs within the program time frame. Perform initial assessment of identified members for Care Management Services within the program time frame and document in care management module. Complete Risk Stratification on enrolled members in CM Programs within the program time frame and document Contact providers of enrolled members within the CM program specification. Develop Care Management action plans for members within the Care Management Programs in collaboration with members and providers within the program time frame. Identify applicable educational materials/resources and provide for member in welcome packet. Obtain and review clinical data, labs, medication history as indicated. Review authorization requests for medical necessity and process per Medical Affairs UM directives. Initiate referrals as indicated (i.e. to Behavioral Health, Complex Case Management, Community Health Worker, etc).

20% Ongoing Interventions- Record all Care Management activities and contacts within the Care Management Module on a routine and timely basis within the program time frame. Members follow up contacts completed per program guidelines and/or as documented in action plan as next review date. Review and update Care Management Action plans as warranted and in collaboration with the provider and member. Provide ongoing education to members regarding self-management of disease process. Monitor events and outcomes of members within the Care Management Program in relation to the action plans. Notify provider of member’s progress or completion of goals.

20% Quality/Process Improvement- Works collaboratively with Team Leader, Manager and Director to recommend design, redesign or enhancement to program descriptions and/or supporting materials. Participation in member events, member educational events and health fairs in collaboration with CHC outreach staff. Participates in team meetings and provides recommendations for process improvement opportunities. Demonstrates knowledge of program requirements and disease process.

10% Actively contributes to achievement of departmental goals, as identified in Department’s annual business plan, including specific departmental process improvement plans. Other duties as assigned.

Education/Specialized Training/Licensure: RN, current Texas License CCM required or must receive within 18 months of employment

Work Experience (Years and Area): 3 years of clinical experience.

Software Proficiencies: Microsoft Office (Word, Excel,Outlook).