Springfield, IL Area – Remote Case Management RN
- Specialty License RN
- State License(s) IL
Medical Associates is looking for Case Management Nurses to join our team as we enter the Springfield market in providing fully insured and self-funded employee benefits and our Medicare Plan!
Case Management Nurse (RN), potential remote, work-from-home position. Full-time, Mon – Fri. Pharmacy knowledge is helpful but not required.
What You Will Be Doing:
- Coordinate and manage the continuance of patient care through a systemic collaborative approach which includes: assessment, planning, implementation, evaluation and interaction.
- Actively participate with your clients to identify and facilitate options and services for meeting individuals’ health needs with the goal of decreasing fragmentation, duplication of care and enhancing quality, cost effective clinical outcomes.
- Monitor general utilization patterns of assigned groups to detect trending patterns.
- Verify benefits information related to out of plan referrals, out of area care, and alternative methods of treatment to hospitalization.
Essential Functions & Responsibilities:
- Identify appropriate patients for case management, disease management intervention per established criteria. Perform case and disease management responsibilities including: telephone duties inclusive of physician referrals, medication reviews, admissions, utilization review updates, investigating alternatives to hospitalization such as home health care and durable medical equipment, utilizing the assessment process by obtaining pertinent patient history and accurate vital data, anticipating patient and family needs, working with the other staff to determine benefit eligibility, facilitating crisis intervention, sharing information with co workers and documenting accurately.
- Facilitate out of plan referrals, out of area urgent and emergent care for enrollees and provider offices and provide necessary information to Medical Director on specified referrals. Communicate decision to enrollees, providers, and facilities per established policies.
- Communicate with enrollees regarding the use of managed care systems and participate in answering enrollees and providers inquiries.
- Document authorizations, denials, cost savings and other outcomes measurements.
- Work collaboratively with internal and external staff, in determining extent of benefits and coverage for services being coordinated.
- Conduct telephonic concurrent medical record review of admissions, based on established screening criteria, facilitating the transition of the enrollee through the health care delivery system.
- Act as a resource for the enrollee, provider offices, and other departments. Perform retrospective review to determine coverage of hospitalizations, and outpatient services.
- Assist in preparations for external review/regulatory agencies.
Knowledge, Skills and Abilities:
Experience – Three years to five years of similar or related experience.
Education – Valid RN nursing license is required.
Stooping – Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.
Reaching – Extending hand(s) and arm(s) in any direction.
Standing – Particularly for sustained periods of time.
Walking – Moving about on foot to accomplish tasks, particularly for long distances.
Lifting – Raising objects from a lower to a higher position or moving objects horizontally from position-to-position. This factor is important if it occurs to a considerable degree and requires the substantial use of the upper extremities and back muscles.
Fingering – Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand or arm as in handling.
Grasping – Applying pressure to an object with the fingers and palm.
Talking – Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly or quickly.
Hearing – Perceiving the nature of sound with or without correction. Ability to receive detailed information through oral communication and to make fine discriminations in sound, such as when making fine adjustments on machined parts.
Vision – 20 / 40 or better in the best eye with or without correction.
Repetitive Motions – Substantial movements (motions) of the wrists, hands and/or fingers.
Sedentary Work – Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
None – The worker is not substantially exposed to adverse environmental conditions (such as in typical office or administrative work).