SUMMARY:
Responsible for utilizing the nursing process in the development of treatment plans, with established goals, implementation, monitoring, and evaluation of an assigned patient caseloads to provide quality care appropriate to clinical needs.
RESPONSIBILITIES/TASKS:
Review and analyze referrals from a variety of sources for acceptance into the program. Evaluate patient needs, identify, and recommend cost-effective health care options. Assure member health needs are consistent with nursing standards and practices, provide recommendations. Develop and monitor action plans established between member, family and/or designee and physician. Develop preauthorization review plans for the review of RN clinical cases. Plan for DME supplies, medications, community resources and facilities. Educate patient and family and/or designee to processes, care practices, medication(s), and benefits. Review prescription drug coverage requests, transplant services, acute organ rejection episodes and/or requests for coverage Prepare documentation, communicate findings, and submit recommendations to medical policy, group representatives, and members of the health care team. (i.e., provider, subscriber, family) Coordinate the member appeals process for DOL, PA250/blended cases. Ensure clinical outcomes are met preventing future re-implantation. Review patient status, educate patient on self-management and ensure appropriate levels of post care education are provided. Identify potential gaps in member discharge to be avoided through education, empowerment and/or motivational interviewing. Clinical review of claims to ensure that correct reimbursement occurs. Internal peer review for quality performance May conduct patient home visits to guarantee that the setting is safe and medical services are delivered. Continues professional development by attending relevant educational programs at lease annually.This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
EMPLOYMENT QUALIFICATIONS:EDUCATION:Nursing diploma or associate degree in nursing required. Bachelor's degree in nursing or related field preferred. Registered Nurse with current Michigan Registered Nurse license required. Certification in Case Management (CCM) preferred upon hire but must be obtained within 24 months of eligible employment. Certification in Chronic Care Professional (CCP) preferred. North American Transplant Coordinator Association certification preferred. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
EXPERIENCE: Two (2) to four (4) years of related clinical experience required. One (1) to three (3) years internal experience preferred.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: Must have basic computer knowledge, typing capability and proficiency in Microsoft Word and Outlook Knowledge of CM/DM principles, CCM Admin Modules, Care Advance system, Prism, NASCO and P&P VDA, MEDCO, NCSW, Coaches Desktop, COSTCAI, HOTP database where applicable Knowledge of HIPAA, American Disability Act, Clinical ethics, COB rules and Medical Policy Familiarity with InterQual criteria, crises call interventions, evidence-based guidelines, and alternate care. Knowledge of educational assessments and learning strategies Knowledge of medical surgical principals, discharge planning, chronic diseases, and clinical programs Ability to negotiate rates with par and non-par providers for extra and non-contractual services. Ability to develop financial plans. Knowledge of current trends in related fields Knowledge of benefits Effective written and verbal communication and feedback Effective organizational skills, ability to prioritize and flexibility. Daily travel to assigned on-site facility (Blue Care Connect Case Managers required) Valid current Michigan driver's license and personal means of reliable transportation for nurses on-site (Blue Care Connect Case Managers required) Proof of auto liability coverage for nurses on-site (Blue Care Connect Case Managers required)WORKING CONDITIONS:Work is performed in an office or remote setting with no unusual hazards.
PAY RANGE: Actual compensation decision relies on the consideration of internal equity, candidate's skills and professional experience, geographic location, market, and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $60,800 and $101,700.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge, and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.
APPENDIX:Transplant Knowledge and understanding of the facility and provider environment as it relates to transplantations. Responsible for the collaborative team input and efforts in the development, implementation, and follow up of cases within the Human Organ Transplant Program. Responsible for monitoring transplant programs with the Medical and Care Management Operations area. This encompasses all specified solid organ transplants and bone marrow/peripheral stem cell transplants.Care Coordinator/Discharge Planner
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