RN Case Manager II - Dual SNP

Centene Coproration in New York, NY

  • Industry: -
  • Type: Full Time
position filled
Description: Position Purpose: The Case Manager/Care Coordinator II is responsible for the coordination of services and cost effective management of health care resources to meet individual members' health care needs and promote positive health outcomes. Acts as a member advocate and a liaison between providers, members and HN to seamlessly integrate complex services. Case Management services are generally focused on members who fall into one or more high risk or high cost groups and require significant clinical judgment, independent analysis, critical-thinking, detailed knowledge of departmental procedures, clinical guidelines, community resources, contracting and community standards of care. Case Management includes assessment, coordination, planning, monitoring and evaluation of multiple environments. Manages individual member cases by coordinating the provisions of services, assuring the cost-effective utilization of health care resources to meet individual members' health care needs and promote positive health outcomes. Significant clinical judgement, independent analysis, critical-thinking, detailed knowledge of departmental procedures, clinical guidelines, community resources, contracting and community standards of care are applied during case management activities. The case manager/care coordinator acts as a member advocate and a liaison between providers, member and HN to seamlessly integrate complex services. Screens members for possible case management services. Participates in programs to proactively identify members at risk who are appropriate for case management services. Reviews, screens and prioritizes cases for possible case management services. Expedites access to appropriate care for members with urgent or immediate needs using expedited review process. Performs comprehensive case assessment. Acquires appropriate clinical records, clinical guidelines, policies, EOC, Benefit Policy and coding guidelines. Performs research and analyzes on complex issues. Assesses the member's current health status, resource utilization, past and present treatment plan and services; prognosis, short and long term goals, treatment and provider options. Using professional judgement, independent analysis and critical-thinking skills applies clinical guidelines, policies, benefit plans, etc to determine the appropriate level of care, intensity of service, length of stay and place of service. Identifies existing problems; anticipates potential problems and acts to avoid them. Develops plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs. Identifies appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities/vendors. Works with the member/family, provider(s), and other members of the health care team to develop a plan of care that enhances the clinical outcome while maximizing the member's benefits. Applies evidence-based guidelines when available. Effectively utilizes community resources and care alternatives. Implements and coordinates interventions and other activities that lead to the accomplishment of goals established in the case management plan. Continually reassesses services delivered to the member to determine if the goals of the plan of care are being met, whether the goals continue to be appropriate and realistic, and what actions may be implemented to enhance positive outcomes. Monitors information from all relevant sources about the case management plan and interventions to determine the plan's effectiveness. Revises care plan when goals are met, new needs are identified, or changes in interventions are made. Performs evaluation in multiple environments including process and relationships, health care management, community resource and support, service delivery, psychosocial intervention and rehabilitation. Closes cases according to the defined case closure procedure in a timely manner, and in accordance with guidelines established. Other Components of Case Management Develops appropriate documentation and correspondence reflecting determination. Assures accuracy, completeness and conformance to standards. Recognizes potential quality care concerns and refers as appropriate. Identifies and refers members who may benefit from disease management. Identifies potential reinsurance cases and notifies the appropriate department according to policy and procedure. Identifies potential TPL/COB cases, investigate TPL/COB issues and notify the appropriate internal departments. Collaborates and communicates with hospitalists, attending physicians and utilization management staff and other health care professionals when appropriate. Identifies cases needing Medical Director review or input. Presents cases to Medical Director for potential review or determinations when needed. Refers potentially inappropriate resource utilization or quality related concerns to Medical Directors. Performs prospective, concurrent and retrospective reviews and first level determination approvals for assigned members, as appropriate, or refers reviews to appropriate associate. Utilizes considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times and regulatory requirements. Works closely with delegated or contracted providers, groups or entities (as assigned) to assure effective and efficient care coordination. Evaluates case management programs of delegated entities. Assesses contracted provider performance against goals on a regular basis. Makes recommendations regarding oversight or joint-management of members. Other Responsibilities: Meets or exceeds established performance goals including but not limited to quality, productivity, turn-around time. Prepares reports, data or other materials for committee presentation. Provides feedback on the effectiveness of policies and procedures. Effectively applies, interprets and communicates policies, procedures, clinical guidelines, medical policy, regulations and standards. Reports suspected fraud and abuse as per company policy. Maintains confidentiality of all PHI in compliance with state and federal law and Health Net Policy. Performs all other duties as assigned.

You may be interested in these similar jobs!
General Restaurant Manager – Grab & Go Concept!
CoRecruitment in New York City , NY

General Restaurant Manager – Grab & Go Concept! Salary: Ranging from $55K - $72K + 30% Yearly Salary Bonus and much much more! Location: NYC, N…

Read More
Program Associate
L Marks in New York, NY

Program Associate - Intrapreneurship L Marks is working to transform corporate businesses by promoting the ideas of their entrepreneurial employees. …

Read More
Senior Production Engineer
Triple H Construction in Jamacia, NY

Job title: Senior Production Engineer Salary: …

Read More
Telephonic Case Manager
Medix in New York, NY

JOB DESCRIPTION Telephonic Case Manager? The Care Manager plans and manages behavioral and/or physical care with members and their beneficiaries …

Read More
Rn case manager/care spec ii non ca
Fidelis Care in Forest Hills, NY

Job Description Position Purpose: The Case Manager/Care Coordinator II is responsible for the coordination of services and cost effective management …

Read More
Medicare Enrollment Agent
Hamaspik Choice in Monsey, NY

Medicare Enrollment AgentWe are seeking a Medicare Enrollment Agent to assist individuals in our coverage area through the important decision-making …

Read More
Nurse Case Manager I/II/Sr.
Anthem in College Point, NY

Nurse Case Manager I/II/Sr.**Location:** **United States****New****Requisition #:** PS32696**Post Date:** 2 days ago**Your Talent. Our Vision** . At …

Read More
Care Manager II (RN)
Fidelis Care in New York, NY

Description: Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services acr…

Read More
Case Manager, RN
Winston Staffing in New York, NY

New York-New York City - Case Manager, RN Our partners, some of the most prestigious hospitals and medical facilities located in the New York Metropo…

Read More
Nurse Case Manager- Developmental Disabilities
PRIDE Health in New York, NY

A large social services organization has a need for two FT RN Case Managers (OPWDD) to cover two residences each in Brooklyn (Borough Park & Crown He…

Read More
RN, CCM Case Manager
CareNational in New York, NY

Case Management Nurse (RN, CCM) - Managed CareManhattan, NY (Financial District / Wall Street Area)*** Certification in Case Management (CCM) is requ…

Read More
Nurse Case Manager
PRIDE Health in Far Rockaway, NY

A leading assisted living facility in Queens seeks a Nurse Case Manager. Responsibilities: Primary responsibility for case management and care plan …

Read More
RN Case Manager
Confidential in Bronx, NY

Our groundbreaking hospice and palliative care programs offer a broad range of services in facilities and the community to help patients and their fa…

Read More
Youth Sales Representative
Riddell in Long Island, NY

Youth Sales RepresentativeRiddell is a premier designer and developer of football helmets, protective sports equipment, head impact monitoring techno…

Read More