RN Case Manager

Responsibilities

• Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care.
• Develop and document a case management care plan in direct collaboration with the beneficiary, the beneficiary's family or significant other(s), the primary physician and other health care providers. Identify and include key concerns, needs, and preferences of the beneficiary and family/caregiver.
• Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan.
• Coordinate and implement the activities specified in the care plan to provide optimal benefits coverage as well as promote continuity of care and integration of services for the beneficiary across care transitions. Collaborate and communicate with the beneficiary, family, significant other(s), physician, and other health care providers to accomplish the goals on the care plan.
• Monitor and continually evaluate the care plan on a scheduled basis to ensure it remains effective and to determine if desired outcomes are met and the goals are achieved. Revise and update the care plan as needed in collaboration with the beneficiary and the health care team.
• Initiate care conferences with Medical Director and/or the multidisciplinary care team to discuss challenging beneficiary cases and obtain expert clinical opinion or consultation.
• Serve as beneficiary advocate by promoting self-determination, informed and shared decision-making, autonomy, and self-advocacy for beneficiaries. Empower beneficiaries by providing education and support to reinforce self-care management, facilitate access to care, and promote optimal health outcomes.
• Identify relevant benefit-related, educational, and health care resources for beneficiaries. Facilitate coordination of care with existing community-based programs and services to meet the identified needs of the beneficiary.
• Demonstrate and apply knowledge of the philosophy/principles of comprehensive case management, patient-centered, culturally sensitive care coordination, and management of complex conditions throughout the case management process.