Primary Nurse Case Admin I - Case Management
Company: HCSC
Location: Chicago
Posted on: March 20, 2023
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Job Description:
Primary Nurse Case Admin IAt HCSC, we consider our employees the
cornerstone of our business and the foundation to our success. We
enable employees to craft their career with curated development
plans that set their learning path to a rewarding and fulfilling
career.
Come join us and be part of a purpose driven company who is
invested in your future!
Job Summary
Case Management (Cm) And Disease Management (Dm). Is A Single
Source Of Contact For Members, Health Care Personnel And All Other
Entities Involved In Managing Care. The Primary Nurse Coordinator
Performs Concurrent Review, Discharge Planning And Care
Coordination. Identifies Alternate Treatment Programs; Consults
With Physicians, Providers, Members, And Other Resources To
Evaluate Options And Services Required To Meet An Individual *S
Health Needs. Promotes Quality And Cost Effective Outcomes; And
Serves As Liaison To Physicians And Members. Other Functions Also
Include Episodic Case Management, Determining Member Assignment Of
Treatment, And Pre-Admission/Post-Discharge Counseling For An Acute
Condition. Establish Relationship With The Member Through The
Immediate Post Discharge Follow-Up Period Or Until All Short Term
Care Needs Are Met. Provide Education/Local Resource Information
And Encourage Member (Self) Education. Functioning In A Clinical
Care Advisory Role, The Primary Nurse Coordinator Assesses Members
For Wellness Education And Disease Management, Introduces Members
To Our Website Tools, Educates Members Regarding Wellness And
Specific Conditions, And Facilitates The Coordination Of Care For
Identified Members.
Responsibilities
This role will telecommute full time. Applicants in IA, IN, MO, WI
will also be considered so long as they are within a 250 mile
radius from posted location and hold a current compact nursing
license
* Perform concurrent review, discharge planning, and alternate
treatment programs. Consult with physicians, hospital UR,
Coordinators and hospital discharge planners to determine other
resources and appropriate disposition of such cases. May do on-site
review of cases.
* Apply accepted department criteria to reviews for medical
necessity and appropriateness for all levels of care as required by
group contract.
* Consult with physician, providers, members, and other resources,
as appropriate, to assess, plan, facilitate implementation,
coordinate, monitor, and evaluate options and services required to
meet an individual's health needs, using communication and
available resources to promote quality, cost effective
outcomes.
* Develop alternate plans and assist members/providers to navigate
the health care system optimizing benefits. Refer care options to
network providers.
* Perform discharge care coordination, episodic case management and
pre-admission/post discharge counseling and identification of
alternate treatment options. Consult with physicians, coordinators,
and facility discharge planners to determine other resources and
appropriate disposition of such cases. Provide education,
counseling and referral to other resources to minimize
re-admissions and emergency room episodes.
* Perform additional ongoing functions to support the member in the
transition of care process including consulting with physicians,
providers, members, and other resources, as appropriate, to assess,
plan, facilitate implementation, coordinate, monitor and evaluate
options and services required to meet an individual's acute health
needs, using communication and available resources to promote
quality health outcomes.
* Contact high risk members and attempt to engage them in a
condition specific education program based on condition specific
National Standards of Care. Educate members regarding wellness and
specific conditions based on National Standards of Care.
* Provide supplemental educational materials to member as
required.
* Utilize Motivational Interviewing and Tele selling skills.
* Collaborate with the Medical Directors, as necessary.
* Maintain licensure and maintain and enhance knowledge for
designated area of licensure and regulatory standards by attending
seminars, training sessions, etc.
* Practice within the scope of licensure in accordance with URAC
and NCQA accreditation standards and with the applicable state
Nurse Practice Act.
* Communicate and interact effectively and professionally with
co-workers, management, customers, etc.
* Comply with HIPPA, Diversity Principles, Corporate Integrity,
Compliance Program policies and other applicable corporate and
departmental policies.
* Maintain complete confidentiality of company business.
* Maintain communication with management regarding development
within areas of assigned responsibilities and perform special
projects are required or requested.
JOB REQUIREMENTS:
* Registered Nurse (RN) with current, valid, unrestricted license
in state of operations
* 2 years clinical practice experience of direct clinical care to
the customer
* 1 year experience in Condition Management or Case Management in a
health insurance/managed care setting
* PC proficiency to include Word, Excel, Lotus Notes and database
experience
* Clear and concise verbal and written communication skills
* Knowledge of UM/CM/DM activities and standardized criteria
set
* Familiarity of ancillary services including HHC, SNF, Hospice,
etc
* Verbal and written communication skills; analytical skills; sound
clinical judgment
* Incumbents with nursing licenses in positions/departments
requiring multi-state licenses are required to obtain and maintain
additional current, valid, and unrestricted applicable nursing
licenses in other states as determined by management. Multi-state
license fees will be provided by HCSC. Incumbents with other
clinical licenses are not required to obtain multi-state
licenses.
PREFERRED JOB REQUIREMENTS:
* Experience in managing complex or catastrophic health cases
* Specialty clinical experience in intensive care medicine,
orthopedic, NICU/pediatric, oncology, diabetic member management,
obstetric (low to high risk maternity management)
* Working toward or completion of CCM/CCP/CDE certification or
Advanced degree
* Knowledge of Milliman Guidelines or similar clinical
guidelines
* Knowledge of medical management policies and procedures
Are you being referred to one of our roles? If so, ask your
connection at HCSC about our Employee Referral process!
HCSC Employment Statement:
HCSC is committed to diversity in the workplace and to providing
equal opportunity and affirmative action to employees and
applicants. We are an Equal Opportunity Employment / Affirmative
Action employer dedicated to workforce diversity and a drug-free
and smoke-free workplace. Drug screening and background
investigation are required, as allowed by law. All qualified
applicants will receive consideration for employment without regard
to race, color, religion, sex, sexual orientation, gender identity,
national origin, disability, or protected veteran status.
Keywords: HCSC, Chicago , Primary Nurse Case Admin I - Case Management, Administration, Clerical , Chicago, Illinois
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