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Registered Nurse/Case Manager job in Washington at AGEATIA

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Registered Nurse/Case Manager at AGEATIA

Registered Nurse/Case Manager

AGEATIA Washington, DC Full Time
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Required Education/Experience/Skills/Abilities:
  • Registered Nurse in the District of Columbia in good standing
  • Bachelor's Degree in Nursing preferred
  • Certified Case Management Certification preferred and must be obtained within 2 years from hire date
  • Three to Five Years of experience in case management in homecare, hospice, or managed care

  • Identification/Risk Stratification :) Engages enrollees into the case management program (outreach and successful enrollment) using diagnostic cost grouper classification reports, which identify the relative risk score and illness burden. Identifying catastrophic health care users with significant health care costs in the High Intensity care needs.
  • Assessment: Conducts and documents a comprehensive assessment of the enrollee's health psych/social needs, including health literacy and deficits. Obtains verbal consent to initiate case management services. Gathers clinical, which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include available support systems, available benefits, community resources, and treatment and medication compliance according to NCQA Case Management Accreditation.
  • Planning: Proficient case management clinical knowledge and experience to coordinate integrated care-plan development involving the enrollee, family, Hospital Transition of Care (HTC) nurse, Care Coordination (CC) and Care Manager (RNCM), Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition and meet NCQA standards of documentation for Case Management Accreditation
  • Facilitation of Communication and Care Coordination: Executing the transition of care includes moving the enrollee from one healthcare practitioner and setting to another as their healthcare needs change. One key responsibility of the case manager is to minimize the fragmentation of care services and adverse outcomes. Completes a review of service request containing all appropriate information (clinical, medical policy, contact/complex benefit structure, FDA treatment, clinical trials and drugs) to allow the medical director to make a medical necessity determination. Identifies and provide educational and community resources, support groups, pharmacy program and financial assistance.
  • Monitoring: Documentation will reflect the necessary communication with the enrollee, family, physicians, and other health care providers to ensure the enrollee's progression in meeting the established care plan goals.
  • Outcomes Management: Evaluate the extent to which the established goals in the plan of care have been achieved.

Portal Data Base: Case management documentation is completed in the Care Connect system
  • Claims: Assists in claims inquiries and resolution
  • Legacy Systems (MHC, Care Connect and OSSE): Confirms enrollee eligibility and available benefits
  • Care Planner Web: Authorization management; generates coverage and adverse decision correspondence using appropriate language to meet state, federal and all regulatory requirements
  • Employer Group/Accreditation Audits: Participates in the preparation and on-site reviews (NCQA, OSR and DHCF)
  • Knowledgeable of federal/state mandates as they apply to various plan contracts
  • Documentation Audit: Responsible for completion of documentation review and peer to peer audit as assigned by management
  • MCG Chronic Care Guidelines: Familiarity with and usage of for the purpose of discharge planning (and length of stay review for FEP Line of Business only)
  • NCQA Compliance: Responsible for adherence to the NCQA Complex Case Management Standards and Health Plan Standards
CMSA: Adheres to the CMSA Standards of Practice for Case Management
  • HIPAA: Maintains confidentiality of patient information according to HIPAA and departmental policies.

  • Assist in the training and re-training of RN Care Managers, Care Coordinators and Community Health Workers
  • Complete task management
  • Assist during staffing challenges
  • Share in the duty of coverage at Wellness Center

Recommended Skills

  • Auditing
  • Care Coordination
  • Case Management
  • Certified Nurse Practitioner
  • Claim Processing
  • Clinical Trials
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