POSITION SUMMARY
This position will be responsible to manage the complex chronic and rising risk members in the populations where care management is delegated to do so. He/she will be the main point of contact for members and providers across care settings. The aim is to better manage patients in the ambulatory setting by following patients deemed as or of becoming heavy users of care due to multiple chronic illnesses, high ED utilization, or a recent discharge from a skilled nursing facility, etc. The RN engages the appropriate resources within the multidisciplinary team to achieve optimal results for the patient, family, and care givers. This position provides comprehensive care coordination for patients as assigned. This position assesses the patient's plan of care and develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, facilitating options and services to meet the patients' health care needs.

CORE FUNCTIONS
1. Manages individual patients across the health care continuum (longitudinal support) to achieve the optimal clinical, financial, operational, and satisfaction outcomes. Provides disease management or referral to disease management support in ancillary areas (i.e. pharmacy, social work, palliative, etc.)

2. Acts in a leadership function to collaboratively develop and manage the interdisciplinary patient care plan. Effectively communicates the plan across the continuum of care. Ensures care plan consistency across providers.

3. Acts in a leadership function with process improvement activities for populations of patients. Provides patient monitoring, education, and supports patient care plan adherence.

4. Promotes a more active and informed role in patient self-care; navigates patients identified as high-risk across the continuum, longitudinally.

5. Establishes and promotes a collaborative relationship with physicians, payers, and other members of the health care team. Collects and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements.

6. Educates internal members of the health care team on care management and managed care concepts. Facilitates integration of concepts into daily practice.

7. This position has the freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are entity based with no budgetary responsibility. Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External customers: Physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.

MINIMUM QUALIFICATIONS
Must possess knowledge of case management or utilization review as normally obtained through the completion of a bachelor's degree in case management or health care.

Requires current Registered Nurse (R.N.) license in state worked. For assignments in an acute care setting, Basic Life Support (BLS) certification is also required.

3 years of experience directly related to Care Management in a Health Plan, Health Management, or Quality.

PREFERRED QUALIFICATIONS
Certification with nationally recognized healthcare organization, such as CCM, preferred.

Additional related education and/or experience preferred.

DATE APPROVED 01/01/2017