JOB SUMMARY
Responsible for performing telephonic or face-to-face clinical assessments for the identification, evaluation, coordination, and management of member's needs, including physical health, behavioral health, social services and long-term services and supports. Identifies members for high-risk complications and coordinates care in conjunction with the member and the health care team. Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits.Obtains a thorough and accurate member history to develop an individual care plan. Establishes short- and long-term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs. The RN has overall responsibility to develop the care plan for services for the member and ensures the member's access to those services. May assist with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible.Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on the development of care management treatment plans. May also assist in problem solving with providers, claims or service issues. Directs and/or supervises the work of any LPN/LVN, LSW, LCSW, LMSW, and other licensed professionals other than an RN, in coordinating services for the member by, for example, assigning appropriate tasks to the non-RN clinicians, verifying and interpreting member information obtained by these individuals, conducting additional assessments, as necessary, to develop, monitor, evaluate, and revise the member's care plan to meet the member's needs, and reviewing and providing input on the non-RN clinicians' performance on a regular basis. Assists in meeting member needs by referring members to internal and external resources. Provide follow up with internal and external resources, providers, and state programs. Coordinate with and participate in ICT meetings with Nursing Facility Staff, member, Responsible Party, treating physicians, therapists, and any other applicable parties. Coordinate and assist with the transition to the community through the Money Follows the Person (MFP) process for any member who indicates a desire to leave the nursing facility.
Marginal Functions
- Provide input and/or data to direct supervisor/manager related to any internal or external mandatory audit or reporting.
- Serve as mentor, subject matter expert or preceptor to new staff.
- Involved in process improvement initiatives.
- Assist in problem solving with providers, claims or service issues.
- Community Health Choices Core Competencies
Customer Focus:
- Reliability and Dependability
- Honest and Integrity
- Change Management
- Teamwork
- Impact/Influence + Strategic Vision
- People/Team Development
- Other duties as assigned.
MINIMUM QUALIFICATIONS:
- Education/Specialized Training/Licensure: Requires a current unrestricted RN license in Texas, Graduate of an accredited school of nursing.
- Bachelors degree in nursing preferred.
- CCM
- Work Experience (Years and Area): 3-4 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience, which would provide an equivalent background.
- 1 year experience working with population who receive waiver services,1 year experience working with persons with disabilities/chronic conditions and Long-Term Services & Supports.
- Software Proficiencies: Microsoft Office, Clinical documentation platforms, Internet
- Other: Local travel required.
- Reliable transportation with valid drivers license with good driving record
