RN II - Oncology Case Manager-REMOTE

About the Role

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed.

• Assess patient’s clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
• Evaluate the necessity, appropriateness and efficiency of medical services and procedures provided.
• Coordinate and assist in implementation of plan for members.
• Monitor and coordinate services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinate with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Coordinate the delivery of high quality, cost‑effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
• Monitor patient’s medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
• Advocate for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
• Encourage member participation and compliance in the case/disease management program efforts.
• Document accurately and comprehensively based on the standards of practice and current organization policies.
• Interact and communicate with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
• Understand fiscal accountability and its impact on the utilization of resources, proceeding to self‑care outcomes.
• Evaluate care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
• Serve as mentor/trainer to new RN's and other staff as needed.
• Act as subject matter expert for respective area for projects.
• May assume leadership type activities in team lead’s absence.
• Represent clinical teams within committee meetings.
• Present reports required at committee meetings.
• Subject matter expert for user acceptance testing for medical management system.

• Outreaches to members identified by Horizon as needing Clinical Advocate services.
• Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast‑paced environment.
• Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques.
• Becomes knowledgeable in ASO client employer‑sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language.
• Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Focuses on whole‑person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well‑being physical, mental, and emotional.
• Schedule:
  
  8‑ or 10‑hour workday Monday through Friday varying between 8am and 11pm.

Education/

Experience:

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree.
• Requires a minimum of two (2) years clinical experience.
• Requires minimum of two (2) years’ experience with health care payer experience.

Utilization Management Only (Utilization Inpatient Case Management does NOT apply to RN II role within HCS):

• RN's are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may…