Job Summary:
Under the direction and oversight of the Manager, Inpatient review and Case Management, the Senior Nurse Case Manager is responsible and accountable for coordination of services for Medicare client members referred for complex case management. The Senior Nurse Case Manager coordinates all systems/services needed for an organized, multi-disciplinary, patient centered team approach, and cost-effective care for Medicare Client members. The Senior Nurse Case Manager follows and manages the course of treatment for patients while coordinating care with physicians, nurses, case managers and other staff from outside Vivant Health and within Vivant Health to ensure quality care and safe outcomes. The Senior Nurse Case Manager also conducts initial and ongoing assessments, incorporates disease management protocols, ensures continuity of care through discharge planning and utilization of resources, and shifts cost to appropriate payers.
Responsibilities:
- This level responds to more complex medical issues, serves as a subject matter expert to lower leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives.
- This level also serves as a proctor for new hires and participates in the training and/or retraining of lower-level nurses.
- Assists with development of care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
- Partners with medical staff utilize scientific evidence for best practices, relevant data and compliance with the mission/philosophy, standards, goals and core values.
- Proactively assesses all potential case management identified from either external or internal sources and actively manages all high-risk, high-volume cases throughout the continuum of the member's health care needs or until they reach a maintenance mode.
- Responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum.
- Demonstrates a multidisciplinary approach in identifying problems, communication with the member's PCP, family members, caregivers, other members of the health care team, community resources and the Health Plans.
- Participates in the development of patient focused long/short term goals, implementing, evaluating and modifying the care plan.
- Research and refers members to sources for alternative funding, community services and other services which may provide support to the patient and family.
- Perform duties telephonically or on-site such as at hospitals, member home or provider offices for discharge planning. Primary duties may include but are not limited to: Ensures member access to services appropriate to their health needs.
- Identifies cases for possible peer reviewers to evaluate the appropriateness and necessity of care and or quality of care concerns.
- Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing inpatient and outpatient care.
- Applies managed care techniques to clinical practice within established criteria.
- Provides instruction for members and their families; and serves as liaison between the member, the physician, the hospital and the Plan.
- May also refer to social workers, or other carve out services as needed
- Completes appropriate, accurate and timely, documentation into EMR system every shift
- Expected to provide meet all appropriate metrics.
- Provides ongoing evaluations of member needs and field nursing activities according to the standards established by Vivant Health, as well as the physicians.
- Assists in preparing UM/QI case issues, gathering requested records/responses.
- Possess knowledge of applicable regulatory standards and performs audits based upon these standards
- All other job-related duties relate to the job function or as delegated by the management team.
- Performs related duties consistent with the scope and intent of the position.
- Regular attendance.
- Travel as required.
Other Functions
- Enforces Company policies and safety procedures.
- Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
- Maintain IPA, Health Plan compliance standards.
