RN Care Manager chez HSCSN

This position will require employees to be in the field (D.C) four (4) days a week.

Under the direction of the Supervisory Care Manager, the RN Care Manager (CM) is responsible for providing comprehensive care coordination services to enrollees with high-complexity medical and behavioral needs who are enrolled in the Health Services for Children with Special Needs (HSCSN) health plan. This CM will have a caseload of medically fragile enrollees focusing on medical intervention and associated care coordination needs outlined by the enrollee assigned acuity level. The CM routinely communicates with enrollees on their assigned caseload to assess their needs; develop, monitor, and evaluate treatment plan progress; and assist with coordinating care and referring to appropriate services for enrollees with highly complex medical and psychosocial needs.

Minimum Education
Associate's Degree in Nursing (Required)
Bachelor's Degree in Nursing (Preferred)

Minimum Work Experience
2 years Clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review, Disease Management or Managed Care (Required)
1 year Working in a Public/community health setting. (Required)

Required Skills/Knowledge
Must have an advanced knowledge of clinical standards of care and disease processes.
Must have excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for enrollees. Spanish Speaking preferred
Must be able to provide excellent internal and external customer service.
Must be proficient in the knowledge of available community resources and programs and Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
Must have the ability to produce accurate and comprehensive work products with minimal direction.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external stakeholders within set expectations for service excellence.
Must have a basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).
Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
Facilitates care team meetings, participates in professional, multidisciplinary meetings to include internal and external staff meetings

Required Licenses and Certifications
Registered Nurse DC License Upon Hire (Required) Certified Case Manager (CCM) 1 Year (Preferred)

Job Functions
Essential job duties:

• Manages a caseload as outlined by CASSIP and Care Management Leadership.

• Maintains compliance in accordance with contractual and care management requirements

• Assists in research, and implementation of disease management/population health programs to serve our highest complexity members.

• Conducts outreach and face-to-face visits at a frequency no less than determined by the enrollee’s assigned acuity level or more if needed, with each enrollee/caregiver in their homes, physician’s offices, or other mutually agreed upon locations.

• Assesses enrollees on enrollment and at intervals no less than determined by the enrollee’s acuity level to identify needs/barriers and close gaps in care.

• Identifies over/under utilization promptly, and takes appropriate action according to organizational policy.

• Gathers physical and mental/behavioral health, environmental, psychosocial, and educational information; the CM develops, implements, and updates an accurate, individualized comprehensive care plan for each assigned enrollee in collaboration with the PCP and/or other multi-disciplinary team members, including public agencies.

• Completes routine care coordination and care management activities with attention to quality, timeliness and in compliance with company policy and NCQA standards.

• Consults with Supervisory Care Manager to review and prioritize cases, set objectives, identify, and report potential risk and utilization concerns.

• Accurately and timely documents enrollee findings and interactions according to organizational policy.

• Understands and abides by HSCSN’s Confidentiality policy and procedure regarding enrollee specific information.

• Participates in disposition and discharge planning activities. Contributes to the discharge plan in a timely manner, taking into consideration enrollee/family/significant others and match to healthcare resources.

• Clearly and respectfully communicates verbally and in writing.

• Assists/empowers caregivers or enrollees to participate in care of child /self.

• Assists assigned enrollees and their caregivers in understanding the importance of EPSDT and compliance with all health services. Strives to achieve target rate of compliance for preventive medical and dental services.

• Assists with scheduling and monitors the compliance of mental health/medical appointments. Follows department policies for identifying and reporting noncompliance, missed appointments, and other reportable incidents including communication to primary care provider or specialist.

• Applies advanced knowledge of conditions of target population/standard approaches to care management and care coordination to assigned enrollees.

• Attends multidisciplinary meetings as necessary, including off-site meetings with other involved agencies.

• Receives and reviews reports of visits by vendors or contracted providers to enrollees receiving services and facilitates coordination of follow-up care, as needed.

• Refers enrollee/caregiver to appropriate vendor(s) on DME/assistive technology use. Educates on medication administration, their conditions, and techniques for self-management within the scope of license. Refer, as needed, to the appropriate vendor for additional education.

• Assist enrollees in planning for transitions of care to include but not limited to transitioning from Early Intervention to DCPS; from pediatric to adult providers; transitioning out of HSCSN when the enrollee ages out or is disenrolled for any reason; from outpatient to inpatient or the reverse; and entering or exiting the custody of CFSA, DYRS or any type of institutional care.

• Enters authorizations for services requiring authorization by Care Management staff.

• Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and updates accordingly.

• Uses communication skills which promote understanding and collaboration with enrollees and their families, HSCSN staff, providers and others.

• Positively presents accurate information about HSCSN to enrollees and their families, HSCSN staff, providers, coworkers and the community.

Other job duties:

• May perform other duties in addition to those outlined in this job description.
• This is a Hybrid role, with time spent in the field engaging enrollees in the community

Organizational Accountabilities
Organizational Accountabilities (Staff)
Employee Excellence

• Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved

• Innovates through improvement of care and/or efficiency of operational processes.

• Dedicated to a standard of performance excellence and high quality

All In

• Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems, and resources that promote quality of care, safety, and efficiency

• Identifies, prioritizes and selects alternative solutions to determine best outcome

Action Oriented

• Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands

• Anticipates problems and attempts to solve before they develop

Supervisory Responsibilities

• None

Blood Borne Pathogen Exposure

• Category III: Job does not involve exposure to blood, body fluids, non-intact skin or tissue specimens. Incumbent does not perform or help in emergency medical care or first aid as a part of his/her job.

Protected Health Information Access Level

• Level IV - Full Access Incumbents in this job may access any protected health information associated to a customer's needs, the service(s) rendered and the position's functions.

Working Environment

• This job operates in an office environment.

Physical Requirements

• Sedentary Work: Lifting 10 lbs. maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one that involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Travel Requirements

• None

DC Residents Encourage to Apply