Job: CASE MANAGER

CASE MANAGER

Requisition Number: 28155

Location: NM - Albuquerque

Type of Opportunity: Regular Full-Time

FLSA Classification: EXEMPT

Minimum Experience: 3 years

Minimum Education: Associates Degree

Shift: Days

* Identifies cases appropriate for care coordination.
* Conducts an in-depth assessment which includes, but is not limited to, psychosocial, physical, medical, environmental and financial parameters
* Develops, documents, and implements plan which provides appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs
* Formulates, implements, coordinates, monitors, and evaluates strategies for patients and families collaboratively with health care team.
* Collaborates with physicians, care providers, and ancillary support services to address care management issues for specific patients and disease processes.
* Applies utilization review criteria to assess and document the appropriateness of admission, continued stay, level of care, and readiness for discharge; refers cases that do not meet criteria to designated Physician Advisor.
* Collaborates with physician, caregivers, patient, family, and payer to pro-actively develop and implement discharge plan, as appropriate.
* Refers patients to appropriate inpatient, outpatient, and community resources.
* Advocates for members in caseload.
* Promotes the appropriate use of clinical and financial resources in order to improve quality of care and patient satisfaction
* Performs cost-benefit analyses and negotiates rates with providers and vendors. Interfaces and negotiates with insurance companies and other payers to ensure payment for services.
* Actively participates in the development of clinical guidelines and pathways and incorporates processes into the role of nurse care coordinators.
* Educates providers and other PHS/PHP departments about care coordination services.
* Educates providers on health management strategies which can reduce need for one-on-one care coordination services.
* Facilitates a regional team approach to the coordination and cost effective delivery of quality care and services across the continuum.
* Generates reports, which demonstrate efficacy through direct cost-savings and outcome measures.
* Complies with Case Management Society of America Standards for Case Management Practice and with CCMC Code of Professional Conduct for Case Managers.
* Performs other functions as required.

Bachelors degree in Nursing, Business, or Health related field preferred. RN license required. Five years experience in clinical nursing with a minimum of one to two in case management, utilization management, quality assurance, home care, community health, or occupational health. National certification preferred within 3 years of hire. Computer knowledge to include Windows, Word, Excel, and database systems. Ability to analyze trends based on decision support systems. Business management skills to include, but not limited to, cost/benefit analysis, negotiation, & cost containment. Knowledge in referral coordination to community & private/public resources.