Care Manager RN

<strong>At Emergent Holdings, we&rsquo;re creating an innovative environment where our employees belong authentically, contribute meaningfully, and thrive intentionally &mdash; both personally and professionally.</strong>

Southfield, USA

Emergent Holdings

<p class="p1"><strong>Emergent Holdings is driven by a singular goal &mdash; improving the health and safety of our customers and our communities. How do we do that? We create innovative insurance products, technology solutions, and services to support our key stakeholders &mdash; individuals, employers, providers, and strategic partners &mdash; improving the health and safety of the people and places we serve.</strong></p>

keywords: job description,review,planning,patient care,other duties,education,experience,knowledge,proficiency,work environment


Competitive Compensation and Benefits Package

Overview: <br />Responsible for utilizing the nursing process in the development of treatment plans, with established goals, implementation, monitoring, and evaluation of assigned patient caseloads in order to provide quality care appropriate to clinical needs.<br /><br /> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards.&nbsp;</p>
Responsibilities: <br /> <ul> <li>Review and analyze referrals from a variety of sources for acceptance into the program</li> <li>Evaluate patient needs, identify and recommend cost-effective health care options</li> <li>Assure member health needs are consistent with nursing standards and practices, provide recommendations</li> <li>Develop and monitor action plans established between member, family, and/or designee and physician</li> <li>Develop preauthorization review plans for the review of RN clinical cases&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</li> <li>Make arrangements for DME supplies, medications, community resources, and facilities &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</li> <li>Educate patient and family and/or designee to processes, care practices, medication(s), and benefits&nbsp;&nbsp;</li> <li>Review prescription drug coverage requests, transplant services, acute organ rejection episodes, and/or requests for coverage</li> <li>Prepare documentation, communicate findings and submit recommendations to medical policy, group representatives, and members of the health care team. (i.e. provider, subscriber, family)</li> <li>Coordinate the member appeals process for DOL, PA250/blended cases.</li> <li>Ensure clinical outcomes are met preventing future re-implantation.</li> <li>Review patient status, educate patient on self-management, and ensure appropriate levels of post-care education are provided</li> <li>Identify potential gaps in member discharge to be avoided through education, empowerment, and/or motivational interviewing</li> <li>Clinical review of claims to ensure that correct reimbursement occurs &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</li> <li>Internal peer review for quality performance</li> <li>May conduct patient home visits to guarantee that the setting is safe and medical services are delivered&nbsp;</li> <li>Continues professional development by attending relevant educational programs at lease annually</li> </ul>
Requirements: <br /> <p><strong>EDUCATION:</strong></p> <ul> <li>Nursing diploma or Associate's degree in nursing required.&nbsp;</li> <li>Bachelors degree in nursing or related field preferred.&nbsp;</li> <li>Registered Nurse with current Michigan Registered Nurse license required.&nbsp;</li> <li>Certification in Case Management (CCM) preferred upon hire but must be obtained within 24 months of eligible employment.&nbsp;</li> <li>Certification in Chronic Care Professional (CCP) preferred. &nbsp;</li> <li>North American Transplant Coordinator Association certification preferred.</li> <li>Continuous learning, as defined by the Company&rsquo;s learning philosophy, is required.&nbsp;</li> <li>Certification or progress toward certification is highly preferred and encouraged.</li> </ul> <br /> <p><strong>EXPERIENCE:</strong></p> <ul> <li>Two (2) to four (4) years of related clinical experience required.&nbsp;</li> <li>One (1) to three (3) years internal experience preferred.</li> </ul> <br /> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Must have basic computer knowledge, typing capability, and proficiency in Microsoft Word and Outlook</li> <li>Knowledge of CM/DM principles, CCM Admin Modules, Care Advance system, Prism, NASCO and P&amp;P</li> <li>VDA, MEDCO, NCSW, Coaches Desktop, COSTCAI, HOTP database where applicable</li> <li>Knowledge of HIPAA, American Disability Act, Clinical ethics, COB rules, and Medical Policy</li> <li>Familiarity with InterQual criteria, crises call interventions, evidence-based guidelines, and alternate care</li> <li>Knowledge of educational assessments and learning strategies</li> <li>Knowledge of medical surgical principles, discharge planning, chronic diseases, and clinical programs</li> <li>Ability to negotiate rates with par and nonpar providers for extra and non-contractual services</li> <li>Ability to develop financial plans</li> <li>Knowledge of current trends in related fields</li> <li>Knowledge of benefits</li> <li>Effective written and verbal communication and feedback</li> <li>Effective organizational skills, ability to prioritize, and flexibility</li> <li>Daily travel to assigned on-site facility (Blue Care Connect Case Managers required)</li> <li>Valid current Virginia driver&rsquo;s license and personal means of reliable transportation for nurses on-site (Blue Care Connect Case Managers required)</li> <li>Proof of auto liability coverage for nurses on-site (Blue Care Connect Case Managers required)</li> </ul>