Case Manager, Registered Nurse

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Family Summary/Mission Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.

Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work.

Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

Position Summary/Mission Community Care Case Manager use a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.

Fundamental Components & Physical Requirements Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.

Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.

Interacts with members/clients telephonically or in person.

May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services.

Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate.

Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.

Prepares all required documentation of case work activities as appropriate.

Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes.

May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.

Provides educational and prevention information for best medical outcomes.

Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources.

Conducts an evaluation of members/clients’ needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data.

Utilizes case management processes in compliance with regulatory and company policies and procedures.

Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.

Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes, as well as opportunities to enhance a member’s/client’s overall wellness through integration.

Monitors member/client progress toward desired outcomes through assessment and evaluation.