RN Care Manager - West Valley

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 15 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

In the role of a RN Care Manager, you will leverage your core skills in managed care, patient service, and nursing to provide high-quality care and support to patients. Your premium skills in Acute care experience will enable you to excel in handling complex medical cases and emergencies effectively. With relevant skills in inpatient and outpatient care, you will collaborate with healthcare teams to ensure seamless transitions and continuity of care. Utilize your expertise in patient assessment, medical terminology, and discharge planning to make a meaningful impact on patient outcomes and healthcare delivery.

POSITION DUTIES & RESPONSIBILITIES

• Participates in outreach to Medicare Advantage (MA) members for the Telephonic Care Management Program, including in-home, facility or community visits for members when clinically indicated and in support of Complex Care Management goals.
• Performs ED follow-up calls.
• Facilitates member/family/caregiver education through referrals to Complex Case Management (CCM), Palliative Care (PC), and Telephonic Care Management, and Hospice as appropriate.
• Identifies any psychosocial needs of the member and facilitates referrals to social work and/or behavioral health, as necessary.
• Documents relevant changes in qHMO of member's condition or status, as they occur.
• Completes the initial hospital admission review, and collaborates with AZPC Medical Directors, for medical necessity determination for in-network hospitalized members.
• Performs re-reviews on all status changes, and collaborates with the Medical Director for appropriate status determination.
• Writes appropriate rationales on all reviews that do not meet status requests.
• Performs re-reviews on all disputed Provider Dispute Resolutions (PDR's), and collaborates with the Medical Director for medical necessity determinations.
• Reviews Skilled Nursing Facility, Acute Rehab and Long-Term Acute Care requests for appropriate disposition with the Medical Director, and informs the hospital case manager of decision.

• Assists the Skilled Nursing Facility with discharge planning to ensure timely and safe discharges.
• Identifies and submits to the Quality Department any potential quality issues for review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
• Identifies and submits Potential Quality Incidents (PQIs) to the Medical Director.
• Equally shares in after-hours, weekend rotation and Holiday coverage for Care Coordination Department.
• Participates in Interdisciplinary Care Team.
• Strong teamwork philosophy and willingness to accept change proactively.
• Other duties as assigned.

EDUCATION, TRAINING AND EXPERIENCE

• Current, unrestricted AZ Nursing license required. – BSN RN preferred.
• Knowledge of Medicare, state, and local managed care regulations, prior experience in Managed Care setting preferred.
• 5 years acute care of care management experience. Medical, ER, Tele, ICE or other relevant clinical role requiring quick critical thinking experience preferred.
• Must have the ability to present clinical information both accurately and confidently.
• Reliable personal transportation with valid driver's license, current auto insurance, and acceptable driving record required.
• Able to communicate effectively and in a professional manner with all levels of internal staff and external customers.
• Ability to be detail-oriented, able to function under pressure and able to prioritize and re-prioritize tasks as needed.
• Ability to work both independently and as part of a team, with minimal supervision.
• Excellent customer service and communication skills, both oral and written.
• Ability to navigate numerous Electronic Health Records Systems.