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Job Summary:
The Nurse
Care Clinician outreaches to members
identified as Members requiring
assistance with health related
challenges. He/she integrates the
nursing process of assessment, planning,
implementation and evaluation with the
skills of motivational interviewing to
ensure engagement of members and
appropriate care plans development and
healthcare services for members with
chronic illnesses.
Job
Description:
The
Nurse Care Clinician will perform
all or some of the following Job
description:
-
Review potential cases to determine
if Member requires care management
and/or disease management
-
Evaluate the effectiveness of
alternate care services and ensure
that cost effective, quality care is
maintained according to standards
-
Contact members telephonically to
conduct ongoing detailed assessments
of clinical conditions
-
Facilitate the coordination of
services and referral management for
all members opened in care
management
-
Develop an Individual Care Plan (ICP)
per Care Management policy and
collaborates with the members’
physician(s) to discuss ongoing
care, offer potential solutions to
clinical and/or social barriers and
obstacles
-
Advocate for future needs of the
member
-
Facilitate interdisciplinary
teamwork to ensure coordination of
care through participation in
rounds, team meetings, and chart
reviews
-
Documents clinical assessments and
coordination of care in the medical
management information system in a
timely manner that meets regulatory
and accreditation standards as well
as internal policy
-
Utilize data to ensure that clinical
interventions result in improved
clinical outcomes and appropriate
utilization of services at an
appropriate cost
-
Provide follow up to ensure Member
receives recommended screenings and
immunizations
-
Research all aspects of Member care
including but not limited to:
Pharmacy Profile, Claims,
authorizations, hospitalizations and
physician specialty services to form
true “picture” of Member needs
-
Triage cases to CM Select and to
Care Coordinators as appropriate
-
Interact with Physicians, Hospitals
as needed to communicate or receive
essential information related to a
Members care
-
Participate in committees to develop
and implement high quality, cost
effective programs as needed.
Minimum Requirements / Knowledge / Skill
For Nurse Care Clinician Job
-
Experience in a health plan or
insurance environment
-
Experience in acute care and/or
rehab nursing
-
Experience with Medicaid recipients
and community services
-
Experience with FACETS, CCMS,
Interqual or other healthcare
database
-
Strong oral and written
communication skills; ability to
interact within all levels of the
organization as well as with
external contacts
-
Strong organization and time
management skills
-
Ability to work in a fast paced
environment; ability to multi-task
-
Experience with standard Microsoft
Office applications, particularly MS
Outlook and MS Word, and other data
entry processing applications
-
Strong analytical and clinical
problem solving skills.
Minimum Education Requirements /
Certification / Licensure For
Nurse Care Clinician Job
-
Current State licensure as a
Registered Nurse
-
Bachelors Degree in Nursing or
Nursing School Degree with
equivalent relevant work experience
-
3+
years of related experience in an
acute care or health insurance
environment
-
2+
years of experience with
pre-authorization, utilization
review/management, case management,
care coordination, and/or discharge
planning
-
CCM
certification.
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