LPN/RN Position Summary/Mission
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for members through assessment and member-centered care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources, optimal member functioning, and cost-effective outcomes.
- Assessment of Members:
- Through the use of clinical tools and review of member specific health information/data, conducts comprehensive assessments of referred member’s needs/eligibility and, in collaboration with the member’s care team, determines an approach to resolving member issues and/or meeting needs by evaluating the member’s benefit plan and available internal and external programs/services and resources.
- Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex clinical indicators which impact care planning and resolution of member issues.
- Using advanced clinical skills, performs crisis intervention with members experiencing behavioral health or medical crisis and refers them to the appropriate clinical and service providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
- Enhancement of Medical Appropriateness and Quality of Care:
- -Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits.
- -Using a holistic approach consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives. Presents cases at case rounds/conferences to obtain a multidisciplinary perspective and recommendations in order to achieve optimal outcomes.
- -Identifies and escalates quality of care issues through established channels
- -Ability to speak to medical and behavioral health professionals to influence appropriate member care.-Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.
- -Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.-Helps member actively and knowledgably participate with their provider in healthcare decision-making-Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
- -Utilizes negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs.
- Monitoring, Evaluation and Documentation of Care:
- -In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals.
- -Adheres to care management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
- RN or LPN
- 3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
- Case management and discharge planning experience preferred
- Managed Care experience preferred
- Crisis intervention skills preferred
- Unencumbered clinical license in the state where they work
- RN/LPN Diploma, Associates or B.S. degree in nursing is required.
Registered Nurse, RN, LPN, LVN, Licensed Vocational Nurse, Licensed Practical Nurse, Obstetrics, Newborn
Licensed Practical Nurse