CASE MANAGER - RN in CANTON, Ohio at Aultman Health Foundation

Position Summary

• The primary purpose of the Nurse Case Manager within the Case Management Department is to work collaboratively with other disciplines including physicians, nurses, pharmacists and other healthcare and support professionals to provide care coordination across the healthcare continuum for all AultCare and PrimeTime Health Plan enrollees, although the primary focus of the Nurse Case Manager is to work with those enrollees with new catastrophic diagnoses, those who are high dollar, high utilizers, or those with potential to be high risk and high dollar. The Nurse Case Manager works directly with AultCare and PrimeTime Health Plan enrollees to identify barriers to effective care. The Nurse Case Manager is an integral member of the healthcare team who can add insight into psychosocial dynamics and serve as a connection to community-based services that may assist the member in navigating the complex healthcare system successfully. The Nurse Case Manager assists the enrollee to reach the best health possible. The Nurse Case Manager carries a comparable case load as the Social Work Case Manager.

Department Summary

The Case Management Department consists of clinical and support staff that work directly with AultCare and PrimeTime enrollees to provide health care education, assist with navigation of the complex health care system and coordination of care, link with internal programs to promote improved health, and link with community resources to overcome barriers to health care. The Case Management Department works telephonically with enrollees who have complex health conditions and are residing in a home setting. The Case Management Department is required to develop knowledge of healthcare insurance terms and processes, as well as internal departments such as customer service, claims, utilization, appeals, etc. in order to assist the enrollee in progressing through challenges that may arise.

Qualifications

• Graduate of an approved Associates or Bachelors Nursing Program.

• Minimum of 4-5 years of experience in a medical/clinical setting. Type and setting of clinical experience will be considered in lieu of the minimum 4-5 years’ experience.

• Maintains current unrestricted RN licensure in the State of Ohio.

• Basic knowledge of medical terminology.

Department Qualifications

• Demonstrates a willingness to become certified in Case Management or another appropriate professional specialty.

Skills

• Experience with Outlook, Word, Excel, PowerPoint, etc.

• Demonstrates ability to handle frequent interruptions in a courteous and professional manner.

• Effectively communicates with various customers and colleagues.

• Works independently, meets deadlines, and effectively perform multiple tasks. • Exercises independent decision-making capability.

• Demonstrates organizations skills.

• Ability to cope with mental and emotional stressors of the position and deadlines.

• Functions independently with flexibility, integrity, and the ability to work effectively and efficiently with all levels of personnel and colleagues.

Department Skills

• All documentation is housed in the medical management system. Staff must maintain consistent, clear documentation of actions.

• Ability to see larger picture and impact to an enrollee.

• Desire to advocate for enrollees.

• Comfortability in speaking eloquently to enrollees, executives, and small groups as needed.

Responsibilities & Expectations

• Customer service/satisfaction

• Anticipate and follow through with both internal and external customer requests to their satisfaction. Seek assistance of others and other departments when needed.

• Maintain cooperative approach in dealing with colleagues and between departments, creating productive working relationships.

• Be flexible and willing to change.

• Keep lines of communication open.

• Express ideas and information verbally and in writing with appropriate grammar, word usage and organization of ideas clearly and concisely.

• Deal with a diversity of people in a broad range of circumstances.

• Communicate with internal and external customers in a professional manner and maintain positive contact with other medical professionals, discussing treatments, costs, equipment, discharges planning and individual treatment plans.

• Dependability/reliability

• Accept assignments willingly and ensures thorough completion of assignments meeting deadlines.

• Adapt to changes in unplanned workload and job demands while paying attention to detail.

• Seek additional assignments upon completion of own duties as time allows.

• Displays regular and punctual attendance according to the Employee Handbook or departmental guidelines (Three or less occurrences per year is acceptable- excluding any FMLA).

• Participate in orientation of new personnel as requested and across product lines if necessary. • Make appropriate recommendations for changes in day-to day operations..

• Handle difficult and sensitive issues with tact, exercising judgement where necessary and consulting supervisor on major problems and issues.

• Demonstrate initiative in problem-solving. • Complete special projects as assigned.

• Keep within acceptable limitations for break, lunch and vacation schedules.

• Ethical conduct

• Maintain confidentiality of member and employer information at all times.

• Comply with policies, procedures, code of conduct, National Association of Social Workers Code of Ethics, Case Management Society of America (CMSA) Standards, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other governing and accrediting bodies.

• Demonstrate honesty and integrity in all functions and relationships.

• Technical/professional proficiency

• Accurately report and document pertinent information.

• Proficient in use of documentation system as well as multiple other internal and external systems including, but not limited to clinical platforms used by Utilization Management, Disease Management and Pharmacy as well as external vendor platforms.

• Answer incoming telephone calls within three rings maintaining profession behavior during all customer interaction.

• Respond to voice mails in a timely manner.

• Consistently demonstrate ability to multi-task and prioritize work in accordance with organizational position and necessity.

• Utilize the most current CMSA Standards of Practice for Case Management to remain proficient in the case management process.This includes, but is not limited to, the activities of Identification, Screening, Assessment, Planning, Implementation, Coordination, Monitoring, Evaluating Outcomes, and Closure. These activities are carried out with the member, their identified support systems, other health care professionals, community resources, while promoting cost-effective use of resources.

• Demonstrates ability to navigate claims systems to gain pertinent information and accurately check eligibility of members.

• Comply with accreditation standards through comprehensive documentation, mock audits, and participate in audit preparation and presentation.

Department Responsibilities & Expectations

• Maintain superior quality in all job functions, contributing to the successful attainment of department/organizational quality goals.

• Respond positively to changes and new ideas.

• Identify and suggest to appropriate supervisory staff, ideas for quality improvement in departmental operations with the goal of improving efficiency and productivity.

• Actively seek out opportunities and make a contribution, rather than passively accept situations.

• Actively participates in strategic planning, quality improvement, and other employee groups as assigned.

Working Conditions

• Hours of operation are 7:00 AM to 5:00 PM, Monday through Friday, of which an eight-hour shift or flex schedule to be determined, is assigned. Occasional overtime may be necessary to meet deadlines.

• Some travel required for which you will be required to use your own automobile with mileage reimbursements as applicable.

• Lunch periods and breaks are coordinated with other staff to maintain adequate coverage.

• Paid Time Off requests are coordinated with other staff members to maintain adequate coverage according to the policy.

• Subject to frequent interruptions and changes in priority of duties throughout the day.

• Expected to adhere to departmental and Aultman Health Foundation policies and procedures.

• Subject to changes in working shifts at the direction of the supervisor.

• Involved with personnel under various conditions and circumstances.

• Works with highly confidential data, information and situations.

Department Working Conditions

• staff typically work remotely as long as all requirements are met, but are required to come onto to AultCare for some meetings, staff development, audit preparations, and other situations as needed.

• If working onsite at AultCare:

• Works in well-lighted, ventilated areas

• Sits for most of the working day-although standing and occasional mobility throughout the building and to adjoining buildings may be necessary.