Registered Nurse Care Manager (RN CM)

The Registered Nurse Care Manager position is responsible for conducting case management activities in accordance with Veracity Benefits policies and procedures. The position responsibilities include the management of complex, acute assigned cases to ensure the member is being provided with quality, cost-effective health care services to reach optimal health outcomes.

Key Responsibilities

• Coordinate and facilitate member care through assessment, evaluation, planning and implementation via telephonic case management activities.
• Communicate member needs to care team members and follow up accordingly.
• Assist with facilitation of discharge planning when necessary.
• Collaborate with member, family members, physicians, and other care team members to ensure optimal health outcomes.
• Provide education and support to assist member with managing conditions and symptoms.
• Provide guidance and education on how to navigate the healthcare system as well as information regarding the member’s plan benefits and resources available to them.
• Coordinate access to providers, community resources, and health benefits as necessary.
• Provide interventions with the goal to avoid poor health outcomes, reduce readmissions, reduce unnecessary, costly treatment, manage transitions of care, and improve the member’s overall knowledge of their current condition with a focus on enhancing overall wellness.
• Maintain regular contact with member and care team members.
• Accurately and clearly document care management activities included but not limited to member, family member, physician and other team member discussions, review of medical records, emails, faxes, letters, coordination of services, linkage of resources, advocacy, education, and negotiations.
• Assess and summarize member health status, prognosis, treatment plan and anticipated costs.
• Research and provide cost-savings resources such as alternative funding programs, manufacturer assistance, and grants when available.
• Advocate for appropriate level of care when required.
• Assess and act accordingly in response to barriers and psychosocial issues.
• Develop a plan of care to include interventions and projected cost-savings.
• Communicate with Medical Director or Physician Advisor or appropriate leadership personnel when there is a threat to patient safety.
• Participate in regular clinical rounds, staff meetings, and committee meetings.
• Participate in providing feedback and input into care management program services, procedures, and resource needs.
• Advocate on behalf of the member to secure access to quality, cost-effective care and attainment of treatment goals.
• Negotiate discounts or reduced charges when use of a high cost or an out-of-network provider is required.
• Maintain confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
• Coordinate with stop-loss/reinsurance carriers to provide accurate health status, prognosis and anticipated costs as part of the employer group renewal process.

• Registered Nurse with a clear, active and unrestricted license in state of residence
• Multi-state Compact RN license preferred (required upon hire)
• A Bachelors (or higher) degree in a health-related field
• Certification in Case Management (CCM) or equivalent preferred (required within one year of hire)
• Minimum of five (5) years direct patient care experience in an acute care or hospital based setting
• Three (3) to five (5) years of case management or related experience
• Experience working in a managed care setting preferred
• Strong Problem-solving skills are essential
• Excellent typing, computer and documentation skills
• Ability to coordinate and communicate with a multidisciplinary team (internal and external)