Position Purpose: Performs care management duties to assess and coordinate all aspects of medical and supporting services across the continuum of care for complex/high acuity populations with primary medical/physical health needs to promote quality, cost effective care. Develops a personalized care plan / service plan for long-term care members, addresses issues, and educates members and their families/caregivers on services and benefit options available to receive appropriate high-quality care.
Key Details: This is a hybrid position that includes home visits with members and remote work from home. Experience in RN care coordination or case management with adult members (21 or older) in Behavioral Health, Home Health, Long-Term Care, Managed Care, Nursing Rehabilitation, or SNF is required. Schedule: Monday–Friday, 8:00 AM–5:00 PM CST. NO on-call duties, evenings, weekends, or holidays.
Service Delivery Area: Hidalgo County, TX and the surrounding areas near Alto, TX, Edinburg, TX, Donna, TX, Elsa, TX, Edcouch, TX, Alamo, TX, Hidalgo, TX, Mission, TX Pharr, TX, San Juan, TX, Mercedes, TX, McAllen, TX or Weslaco, TX; Mileage reimbursement is provided for member assessment visits.
- Evaluates the service needs of the most complex or high risk/high acuity members and recommends a plan for the best outcome
- Develops and continuously assesses ongoing long-term care plans / service plans and collaborates with care management team to identify providers, specialists, and/or community resources needed to address member's needs
- Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services
- Monitors care plans / service plans and/or member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / needs
- Monitors member status for complications and clinical symptoms or other status changes, including assessment needs for potential entry into a higher level of care and/or waiver eligibility, as applicable
- Reviews member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations
- Reviews referrals information and intake assessments to develop appropriate care plans / service plans
- Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments and determine a revised care plan for member if needed
- Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and clinical guidelines
- Provides and/or facilitates education to long-term care members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits
- Acts as liaison and member advocate between the member/family, physician, and facilities/agencies
- Educates on and coordinates community resources. Provides coordination of service authorization to members and care managers for various services based on service assessment and plans (e.g., meals, employment, housing, foster care, transportation, activities for daily living)
- May perform home and/or other site visits (e.g., once a month or more), such as to assess member needs and collaborate with resources, as required
- Partners with leadership team to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner
- May precept clinical new hires by fostering and building core skills, coaching and facilitating their growth, and guiding through the onboarding process to upskill readiness
- May provide guidance and support to clinical new hires/preceptees in navigating within a Managed Care Organization (MCO) and provides coaching and shadowing opportunities to bridge gap between classroom training and field practice
- May engage and assist New Hire/Preceptee during onboarding journey including responsibility for completing competency check points ensuring readiness for Service Coordination success
- Engages in a collaborative and ongoing process with People Leaders and cross functional teams to measure and monitor readiness
- Performs other duties as assigned
- Complies with all policies and standards
- Travel for member visits is required
Education/Experience
- Graduate from an Accredited School of Nursing
- Requires 4–6 years of related clinical nursing and/or case management and care coordination experience
- Bachelor of Nursing degree is preferred
License/Certification
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
- NP - Nurse Practitioner - Current State's Nurse Licensure
- For Superior Health Plan: Required Resource Utilization Group (RUG) certification must be obtained within 90 days of hire
Pay Range: $36.21 - $65.09 per hour