Care Manager - RN, Triage

Bridgewater MA 02324 One Lakeshore Center

Job Description

TERRITORY PRIMARILY COVERS SOUTHEAST, BUT MUST BE FLEXIBLE
Bilingual candidates strongly preferred

I. Position Summary:
The Nurse Care Manager, Triage is responsible for establishing a professional and supportive “first contact” for new enrollees with complex care needs, conducting initial assessments for services, and providing case management support. In collaboration with the member’s Primary Care Provider (PCP) and an interdisciplinary team, the Nurse Care Manager facilitates development, and implementation of Individual Care Plans (ICP).


II.

Essential Functions

Responsibilities:

• Reviews initial enrollment applications of community dwelling enrollees and using SWH Clinical team triggers as criteria, determine which new enrollees require initial in-home Clinical assessment
• Monitors home visit queue for new enrollees identified through the triage assessment as meeting eligibility for a clinical assessment and performs or delegates clinical assessments, monitor to ensure home visit is scheduled within 30 -60 days of effective date.
• Completes an Initial Clinical Assessment and works within the Interdisciplinary Team (IDT) structure to complete the patient’s initial Plan of Care.
• Educates new enrollees and or their designee on the SWH Model Of Care and plan benefits
• Verifies contact information and other demographic data collected during enrollment process and communicates updates to appropriate personnel to ensure accuracy of data in enrollee’s Centralize Enrollee Record (CER).
• Complete initial documentation on member, hand-off member to assigned Community Nurse Care Manager.
• Evaluates the immediate need for supplies, equipment, and services, and coordinates the provision of these services in accordance with the ICP
• Adhere to SWH documentation policies and procedures including documentation of Care Management activities and their effectiveness.
• Maintaining a comprehensive working knowledge of community resources, payer requirements, and network services for target population
• Analyze data and use it to improve care delivery
• Apply Interqual, Medicare, Medicaid criteria to appropriate services to ensure consistent benefit administration
• Monitor member’s health status and ensure that member is receiving all necessary medical and supportive services.
• Collaborate with other SWH Care Managers to reduce variations in clinical practice, identify opportunities for systems’ improvement, and develop policies and procedures relevant to practice
• Participate with Utilization Management (UM) and Skilled Nursing Facility (SNF) teams to ensure optimal care transitions for members moving between care settings.
• Participate with Pharmacy team to assess and optimize members’ compliance with prescribed medications
• Refer clinical issues appropriately to Clinical Manager, Director, and Medical Director.
• Other duties as assigned
  • Strong clinical and assessment skills
  • Outstanding communication skills
  • Computer skills
  • Ability to work independently and maintain flexibly in fast paced start up environment
  • Ability to analyze data and use it to improve care delivery
  • Self-starter with high level of accountability and responsibility for outcome of care
  • Highly organized and able to manage multiple priorities appropriately
  • Independent problem solving skills

Able to work collaboratively

General Job Information

Title

Care Manager - RN, Triage

Grade

23

Job Family

Clinical Services Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

11/1/2018

Date Requisition Created

11/1/2018

Minimum Qualifications

Education

Associates: Nursing (Required), Bachelors: Nursing

License and Certifications - Required

RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

CCM - Certified Case Manager - Care Mgmt, CCP - Chronic Care Professional - Care Mgmt

Other Job Requirements

Responsibilities

  • Home Care, Long-Term Care, MLTC experience preferred, including appropriate support services in the community and accessing and using durable medical equipment (DME).
  • Experience in utilization review, concurrent review and/or risk management a plus.
  • Bilingual or multilingual fluency preferred.
  • Understands and is able to apply principles of Care Management and Person Centered Service Planning.
  • Ability to apply Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines.
  • Ability to understand and apply coverage guidelines and benefit limitations.
  • Familiar with clinical needs and disease processes for chronic physical and behavioral illnesses (depression, challenging behaviors, Alzheimer's disease and other disease-related dementias).
  • Understands and adapts appropriately to issues related to communication, cognitive or other barriers.
  • Ability to lead an interdisciplinary care team.
  • Strong organizational skills and the ability to prioritize and follow through on multiple projects in a timely manner.
  • Comfortable with conducting home visits and commuting within the service area.
  • Minimum 3 years' clinical experience with focus in managed care, including disease or case management.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled

“I receive a high level of support from our Senior Management Team to execute on our vision. They are always accessible and approachable, something I’ve found to be very unique to Magellan.”