Care Management Nurse - Hybrid
Company: Cambia Health Solutions, Inc
Location: Boise
Posted on: April 22, 2024
Job Description:
Care Management Nurse - Hybrid ID - Independent Doctors of Idaho
(IDID)Primary Job Purpose The Care Management Nurse provides
clinical care management (such as case management, disease
management, and/or care coordination) to best meet the member's
specific healthcare needs and to promote quality and cost-effective
outcomes. Oversees a collaborative process with the member and
those involved in the member's care to assess, plan, implement,
coordinate, monitor and evaluate care as needed. General Functions
and Outcomes
- Responsible for essential activities of case management
including assessment, planning, implementation, coordination,
monitoring and evaluation.
- Assessment: collection of in-depth information about a member's
situation and functioning to identify individual needs.
- Planning: identification of specific objectives, goals, and
actions designed to meet the member's needs as identified in the
assessment.
- Implementation: execution of the specific case management
activities that will lead to accomplishing the goals set forth in
the plan.
- Coordination: organization, securing, integrating and modifying
resources.
- Monitoring: gathering sufficient information to determine the
plan's effectiveness and the evaluation phase should determine the
effectiveness of reaching the desired outcomes. Applies clinical
expertise and judgment to ensure compliance with medical policy,
medical necessity guidelines, and accepted standards of care.
Utilizes evidence-based criteria that incorporates current and
validated clinical research findings. Practices within the scope of
their license.
- Consults with physician advisors to ensure clinically
appropriate determinations.
- Serves as a resource to internal and external customers.
- Collaborates with other departments to resolve claims, quality
of care, member or provider issues.
- Identifies problems or needed changes, recommends resolution,
and participates in quality improvement efforts.
- Responds in writing or by phone to members, providers and
regulatory organizations in a professional manner while protecting
confidentiality of sensitive documents and issues.
- Provides consistent and accurate documentation.
- Plans, organizes and prioritizes assignments to comply with
performance standards, corporate goals, and established
timelines.Minimum Requirements
- Knowledge of health insurance industry trends, technology and
contractual arrangements.
- General computer skills (including use of Microsoft Office,
Outlook, internet search). Familiarity with health care
documentation systems.
- Strong oral, written and interpersonal communication and
customer service skills.
- Ability to interpret policies and procedures, make decisions,
and communicate complex topics effectively.
- Strong organization and time management skills with the ability
to manage workload independently.
- Ability to think critically and make decision within individual
role and responsibility.Normally to be proficient in the
competencies listed above Care Management Nurse would have a/an
Associate or Bachelor's Degree in Nursing or related field and 3
years of case management, utilization management, disease
management, or behavioral health case management experience or
equivalent combination of education and experience. Required
Licenses, Certifications, Registration, Etc. Must have licensure or
certification, in a state or territory of the United States, in a
health or human services discipline that allows the professional to
conduct an assessment independently as permitted within the scope
of practice for the discipline (e.g. medical vs. behavioral health)
and at least 3 years (or full time equivalent) of direct clinical
careMust have at least one of the following: Certification as a
case manager from the URAC-approved list of certifications; or
Bachelor's degree (or higher) in a health or human services-related
field (psychiatric RN or Master's degree in Behavioral Health
preferred for behavioral health care management); or Registered
nurse (RN) license (must have a current unrestricted RN license for
medical care management)Work Environment Duties performed at home
and in Independent Doctors of Idaho - IDID
Keywords: Cambia Health Solutions, Inc, Boise , Care Management Nurse - Hybrid, Executive , Boise, Idaho
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