The Nurse Care Manager is primarily responsible for identifying Trusted Health Plan members appropriate for targeted, high touch community-based integrated care coordination services. The Case Management/Care Coordination (CM/CC) program utilizes a member/family center approach that provides comprehensive case management services to the highest risk health plan members.
ESSENTIAL DUTIES AND RESPONSIBILITIES
The Nurse Care Manager focuses on optimizing Trusted Health Plan members to achieve their highest level of functionality, comfort, energy, independence, and freedom from health risk to enjoy the highest quality of life.
The Nurse Care Manager compiles a comprehensive care management assessment (Health Risk Assessment – HRA) and gathers pertinent information about the members needs by interviewing the member, appropriate family members, physicians, ancillary health professionals and others as necessary.
Individual precision plans of care are developed in collaboration and cooperation with the Member/Care Giver, Physician, Ancillary Health Professionals, Families and others on the Care Team (pharmacist and social worker). Ongoing coaching, monitoring and evaluation of care plans will be done face to face with the member, telephonically or electronically through email, among members and Providers.
Documenting members’ care management plans and on-going activities
Identifying and addressing member risk factors and/or obstacles to care
Identifying member needs, current services, and available resources, then connecting the member to services and resources to meet established goals.
Communicating the care preferences of members, serving as their advocate, and verifying that interventions meet the member’s needs and goals of treatment.
Screening members and/or population for healthcare needs.
Developing a member-focused care management plan.
Educating the member/family/caregiver about the care management process and evaluating their understanding of the process.
Participate in weekly case review to learn and share opportunities to improve outcomes.
Clinical knowledge and experience to bring an understanding of the clinical process of compiling the information of the HRA, planning, implementation, and evaluation to the process of care management. In addition to clinical expertise, care management nurses need excellent communication and problem-solving skills and must know how the health care system works, including regulations, resource availability, and the coverage of medical care.
Active and unrestricted RN License required. Certification in Case Management preferred
Bachelor's Degree in related Health/Nursing field preferred
A minimum of two years of experience in health care, case management, care coordination, discharge planning or utilization management Experience working with case management data systems
Experience working in a managed care environment preferred Proficient in Microsoft Office tools
Should have a high level of understanding of community resources, treatment options, home health availability, funding options and special programs
About Trusted Health Plan
Trusted Health Plans, Inc. (Trusted) is a fully licensed Health Maintenance Organization, operating NCQA and URAC accredited organizations in the District of Columbia and Southeastern Michigan.
Trusted is dedicated to improving the health status of its members through a variety of proven approaches, as well as the introduction of innovative programs to benefit members’ health behaviors. Trusted believes in meeting with members “face to face” to assist them in accessing the health care services and support they deserve. They have partnered with over 5,000 licensed providers throughout D.C. and several thousand throughout the state of Michigan, as well as a variety of social service organizations.
The Trusted team is proud of their model: connecting directly with members and utilizing sophisticated predictive modeling systems to target high-risk members, and executing a “feet in the street” approach to case management and care coordination.
Data supports Trusted’s community-based approach, showing unprecedented savings for Medicaid programs by reducing occurrence rates at the most expensive entry point for healthcare: the emergency room.Between 2014-2016 Trusted on a per th...ousand-member basis, increased primary care visits by 21%, reduced emergency room visits by 14%, and reduced inpatient visits by 5%.
Trusted is in the process of taking it's highly successful model nationwide.