JOB DESCRIPTION
Opportunity for a TX licensed RN with experience working in women's health; specifically, OB, L&D, or postpartum, to join our Texas Health Plan as a Case Manager. Your caseload will consist of members who are pregnant, many of them high risk. Telephonically you will complete assessments needed for determining the types of services we need to provide and managing their care until they are discharged from your service. The ideal candidate will have experience as a Case Manager within a managed care organization (MCO) like Molina, but we also consider RNs with a strong background in women's health. Hours are Monday – Friday, 8 AM – 5 PM CST working from home.
Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, and Teams as well as being confident in moving between different programs to complete the necessary forms and documentation.
Job Summary
Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
- Completes comprehensive member assessments within regulated timelines, including in-person home visits as required.
- Facilitates comprehensive waiver enrollment and disenrollment processes.
- Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals.
- Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.
- Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care.
- Assesses for medical necessity and authorizes all appropriate waiver services.
- Evaluates covered benefits and advises appropriately regarding funding sources.
- Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration.
- Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.
- Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns.
- Identifies critical incidents and develops prevention plans to assure member health and welfare.
- May provide consultation, resources and recommendations to peers as needed.
- Care manager RNs may be assigned complex member cases and medication regimens.
- Care manager RNs may conduct medication reconciliation as needed.
- 25-40% estimated local travel may be required (based upon state/contractual requirements).
Required Qualifications
- At least 2 years of experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience.
- Registered Nurse (RN). License must be active and unrestricted in state of practice.
- In some states, a bachelor's degree in a health care related field may be required (dependent upon state/contractual requirements).
- Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law.
- Ability to operate proactively and demonstrate detail-oriented work.
- Demonstrated knowledge of community resources.
- Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations.
- Ability to work independently, with minimal supervision and demonstrate self-motivation.
- Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations.
- Ability to develop and maintain professional relationships.
- Time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
- Problem-solving skills.
- Strong verbal and written communication skills.
- Microsoft Office suite/applicable software program(s) proficiency.
- In some states, must have at least one year of experience working directly with individuals with substance use disorders.
Preferred Qualifications
- Certified Case Manager (CCM).
- Experience working with populations that receive waiver services.
Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.