This position will sit on-site in our corporate headquarters in Des Moines, IA.
Hiring Specifications Required:
- Completion of an Accredited registered nursing program
- 4+ years of relatable experience:
- 4+ years of clinical experience in an acute care or outpatient setting with a minimum of 4 years full time equivalent of direct clinical care to the consumer
- Active and unrestricted RN license in Iowa or South Dakota (individual must be licensed in the state in which they reside)
- Demonstrated verbal and written communication skills including success to influence others (without direct leadership) and negotiate care with members, physicians, care facilities or similar audiences
- Experience effectively establishing relationships and engaging with patients or members through telephonic communication
- Experience with computer software applications (e.g. electronic charting, Microsoft Suite, documentations systems, etc)
- Knowledgeable of regulatory standards and regulations (e.g. URAC, NCQA, HIPAA, PHI, confidentiality)
- Ability to work a flexible schedule, with shifts between the core hours of 8:30 AM-6:00 PM Monday – Friday
- Ability to travel as needed
- Valid driver’s license required
Hiring Specifications Preferred:
- Bachelors Degree in Nursing, Health Care Administration or Public Health
- Certification as a Certified Case Manager (CCM) Must attain CCM within 24 months after hire, and maintain throughout employment.
- Previous work experience in case management. Includes assessment of members, creating and managing care plans, etc.
- Previous experience working independently and managing an assigned caseload in a metrics based environment
- Demonstrated experience interpreting health care benefits
Proactively identify and provide telephonic complex care management interventions for members. Includes completing assessments to identify barriers to care and gaps in health care, then creating and managing individual care plans that ensure members receive appropriate care and achieve health care goals. Collaborate with members, members’ families, health care providers and community resources to coordinate the care and services provided to members.
- Proactively coordinate care for high-risk members and/or members that are identified with potential high-risk, complex conditions through focused intervention and effective planning techniques. This includes assessing members to identify care needs, barriers & interventions. In collaboration with the member and the member’s health care delivery team, create, manage and update individualized care plans.
- Effectively engage members in the participation of the case management plan and educate members on their accountability and expected outcomes, including services and benefits appropriate to their current medical status.
- Monitor results and trends and make recommendations to leaders/advisory team/groups as appropriate regarding change.
- Actively research and stay abreast of appropriate resources and/or programs that may help to improve the health of the member. Collaborate with and facilitate referrals to providers, community resources/programs and Wellmark programs as necessary.
- Meet caseload expectations for work area assigned through pre-determined case identification logic. Accepts referrals from other programs and from within the case management area. Meet both quality assurance and production metrics as established by the care management unit.
- Document case findings accurately, consistently and timely by following the standard work guidelines and policies to support internal and external processes.
- Apply consistent, accurate interpretation and application of clinical criteria, medical policy, best practice guidelines and benefit information for medical necessity and medical review decisions, as appropriate, for improved member outcomes.
- Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to advanced care management.
- Participate in cross-collaboration among care management teams and stakeholders across divisions as required to provide optimal service to the member.
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