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Primary Nurse Case Admin I - Case Management

Company: HCSC
Location: Chicago
Posted on: November 19, 2023

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.


1. 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. 2. Apply accepted department criteria to reviews for medical necessity and appropriateness for all levels of care as required by group contract. 3. 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. 4. Develop alternate plans and assist members/providers to navigate the health care system optimizing benefits. Refer care options to network providers. 5. 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. 6. 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. 7. 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. 8. Provide supplemental educational materials to member as required. 9. Utilize Motivational Interviewing and Teleselling skills. 10. Collaborate with the Medical Directors, as necessary. 11. Maintain licensure and maintain and enhance knowledge for designated area of licensure and regulatory standards by attending seminars, training sessions, etc. 12. Practice within the scope of licensure in accordance with URAC and NCQA accreditation standards and with the applicable state Nurse Practice Act. 13. Communicate and interact effectively and professionally with co-workers, management, customers, etc. 14. Comply with HIPPA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. 15. Maintain complete confidentiality of company business. 16. 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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