Population Health Case Manager RN

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the Director of Case and Disease Management as required.

General Responsibilities:

• Maintains utmost level of confidentiality at all times.  
• Adheres to Health System and Health Plan policies and procedures.  
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.  Case Manager’s Responsibilities:

Knowledge:
1. Be knowledgeable in Medicaid criteria/guidelines.  2. Be knowledgeable about managed care contracts/guidelines.  3. Be knowledgeable of data-driven decision-making tools and their use.  4. A working knowledge of various reimbursement mechanisms, including third party requirements.  
5. Current working and demonstrated knowledge of various criteria sets (i.e., Inter Qual) preferred.

Responsibilities:  
1. Communicating with members and their support systems, as well as other healthcare providers.  
2. Apply plan benefits consistently for each line of business.  
3. Provides ongoing oversight, availability and monitoring of non-clinical staff activities.  
4. Identify members with special health care needs for possible disease management programs available within the plan.  
5. Negotiate with vendors when necessary for services/equipment.  
6. Ensure appropriate referrals/authorizations to agencies, assistance programs, physicians and other healthcare related programs are completed within established turnaround times.  
7. Coordinate appropriate Community/health agency referrals.
8. Report, as appropriate, potential adult/elder/child abuse cases to appropriate agency and coordinate with Driscoll Health Plan (DHP) Social Workers.  
9. Collaborate with physicians, social workers, nurses, and other multidisciplinary team members as appropriate to obtain optimal outcomes for members.  10. Assess a member’s needs and social support network.  11. Complete documentation about a member’s case management plan of care, progress toward meeting care goals, outcomes, care reports, etc. Managing a member with one or multiple chronic illnesses such as heart failure, diabetes, asthma, ESRD, bipolar disorder, and dual diagnosis.  

12. Complete documentation about a member’s case management plan of care, progress toward meeting care goals, outcomes, care reports, etc. while managing members with Early Childhood Intervention needs.
13. Conducting a case conference to resolve disagreement and/or clarify a plan of care as needed.  14. Serve as the expert resource regarding reimbursement and clinical practice issues.  15. Participates in health plan’s performance improvement activities.
16. Accepts other assignments from management as requested and complies with basic management principals of delegation.

EDUCATION AND/OR

EXPERIENCE:

• One year of acute inpatient case management or managed care case/utilization management experience preferred.

• A minimum of three (3) years prior clinical experience.  
• Graduate of an accredited school of Nursing.  
• Must have a current valid Registered Nursing licensure in the State of Texas without restrictions

CERTIFICATES, LICENSES, REGISTRATIONS:  List the licenses, certificates, or registrations that are required to perform the essential duties of this job.  
• Must have a current, active, and unrestricted Registered Nursing Licensure in the state of Texas.

• Certification in Case Management or Managed Care preferred or strongly preferred to be obtained within two years of employment.
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