Scope:

The Case Manager manages an individual caseload using the Case Management process to meet the needs of MedWatch, LLC customers and consumers. This includes, but is not limited to, authorization of services, review of treatment plans for medical necessity, standards of care, and ongoing communication with all members of the health care team.

Education:

• R.N.

• Bachelor's degree in a health-related field preferred.

Licensure/Certification Requirements:

• Registered Nurse (current active and unrestricted, in state of current practice and residence, within the United States or its territories.)

Experience:

• 7 years of varied clinical experience preferred.

Requirements/Skills:

• Good organizational skills and time management

• Excellent verbal and written communication skills

• Ability to handle difficult situations tactfully and diplomatically.

• Effective problem solving and decision-making skills.

• Strong computer skills with proficiency in MS Office Suite products (Word, Excel, Power Point)

• Must speak fluent English and Spanish with strong reading and writing abilities in each language

Expectations of a Level I RN Case Manager

• Focus

• Managing moderate-complexity cases independently and contributing to team goals

• Key Responsibilities

• Meets Entry Level criteria

• Independently manage a full caseload

• Coordinate care transitions and discharge planning

• Collaborate with providers, social workers, and insurance teams

• Participate in quality improvement initiatives

• Development Goals

• Demonstrate consistent documentation and compliance

• Shows initiative in problem solving and patient advocacy

• Function independently and demonstrate proficiency in managing a case management case load

Duties and Responsibilities:

• The Registered Nurse Case Manager will practice within the scope of his/her licensure.

• Review all medical data which can be provided to establish, update and maintain accountability for a Case Management plan which will incorporate contact with providers, payers, the patient and with the patient's primary caregiver.

• Assess problems and determine goals and actions designed to meet the needs of the patient and document this into the case notes. Determine if these goals are long term or short term and how the patient can be expected to meet those goals. Include the action/intervention the Case Manager will take to work towards achieving those goals.

• Make contact with the payer office to find out and understand any benefit constraints that will have an impact on the plan of action.

• Proceed with contacting medical care providers and with equipment vendors to verify medical necessity of care or equipment that has been ordered.

• Make care arrangements for quality patient care according to the needs of the patient, the physician's orders, and the benefits available.

• The Case Manager will work in conjunction with the Case Management Assistant to manage Case Management files, exclusive of Assessment and/or Care Plan activities, and will provide input in the Annual Performance Evaluation of the CM Assistant assigned. The Case Manager will maintain responsibility for the Case Management file.

• Be aware of any alternative treatment possibilities that may allow the patient to reach wellness goal(s). If there are no benefits available for your recommended alternative treatments, provide to the payer a cost-benefit analysis to demonstrate that extra-contractual services will enhance the patient's medical condition and will be cost-effective to the benefit plan.

• Become familiar with community resources and funding sources so that the patient can receive quality health care and conserve health benefit dollars. Many agencies exist which aid persons in financial need or provide information to persons with specific medical conditions.

• Maintain case in computer system documenting case actions for each patient under your Case Management. Complete all aspects of case in the computer. Prepare timely reports to the payer to detail all case actions, the results of those actions, and the continuing Case Management plan.

• Maintain billing as appropriate in computer system.

• Continue to maintain contact with the providers and with the patient across the continuum of care to be sure that patient needs are being met. On any cases which include a chronic condition keep the file open for periodic contacts to verify the clinical status of the patient and additional medical needs.

• Negotiate with providers to maximize the medical benefits available to the patient. Make network referral as appropriate.

• Act upon any awareness of non-medical issues which involve the patient's safety or welfare. Attempt to direct the patient or family to appropriate providers or community resources, or to personally notify appropriate authorities.

• Consult with the Director of Case Management on a regular basis, and keep the supervisor informed regarding any complaints which may occur about Case Management services or any issues which arise which the Case Manager is not competent to handle or does not have the expertise to handle.

• Adhere to all company policies as stated in the employee handbook.

• All Case Managers will possess a URAC-recognized certification in Case Management within 3 years of hire.

• Participate in the Quality Management Program by adhering to all company policies and procedures and identifying opportunities for improvement to ensure quality services are rendered to clients and customers.

• The incumbent may be responsible for duties or responsibilities that are not listed in this job description. Duties and responsibilities may change at any time with or without notice.
• This position is eligible for a bonus program.

There is a pay differential for Bilingual - Spanish speaking requirement. The salary range for this position is from $72,000 to $81,000 annually.

Work Environment / Physical Demands: This position is in a typical office / home office environment which requires prolonged sitting in front of a computer. Requires hand-eye coordination and manual dexterity sufficient to operate standard office equipment including operation of standard computer and phone equipment.

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