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Provides telephone triage to member of the health plan. Advises and instructs callers on proper health care after assessing the urgency of symptoms or complaints.: Answers telephone inquiries, assesses symptoms and provides assistance to members of the health plan in accordance with established policies, procedures and protocols. Provides clinical nursing evaluation and assessment and instructs callers to seek appropriate medical care. Notifies physician on call with pertinent medical information or if consultation is deemed necessary by nurse. Provides nursing referral to appropriate and available resources, including affiliated services, affiliated medical practice or community resource. Enters data into a computerized database and forwards facsimiles to appropriate health providers. Consults and facilitates after hours communication with physicians, nurses, hospital staff and outside agencies. Communicates with pharmacies and providers to refill medications or to clarify prescriptions. Typically requires graduation from an accredited School of Nursing as a Registered Nurse with two years of hospital or public health nursing experience. May provide health insurance eligibility, pharmacy benefits, provider information, and other information to callers.

Resident Care Coordinator RN

Coordinates the work of all disciplines involved in completing Minimum Data Set (MDS) assessments and resident care plans according to regulatory requirements and guidelines. Provides assistance to the Nursing Director by providing in-service to staff, assessing competencies, and evaluating nursing staff. Plans, supervises, and evaluates the delivery of resident care and activities. Provides nursing care and ensures that nursing procedures are followed. Reviews resident care plans and conducts interdisciplinary care plan conferences. Typically requires completion of a nursing program at an accredited school of nursing as a Registered Nurse and a minimum of three years of nursing experience in a long-term care setting working with MDS. A valid nursing license is required.: Ensures that medical supplies and equipment are maintained on each unit. Oversees documentation to comply with Medicare or state reimbursement rules. Monitors medication passes and treatment schedules to ensure that they are properly administered. Interprets resident charts to accurately complete sections of the MDS. Performs quality improvement audits and assists in the implementation of quality assurance measures. Reviews resident charts for contradictions in information and researches any contradictions to determine what is valid. Reviews and investigates complaints and incident reports.

RN Field Case Manager

Provides ongoing evaluation and nursing case management services, meeting with clients in their homes, work-sites, or physician's or therapist's office. Assesses, evaluates, and analyzes injured workers’ medical and/or vocational status, and develops, coordinates, and implements a viable, realistic service plan. Monitors the progress of the injured/disabled individuals and reports results back to the employer and insurance carrier.: Develops a plan of care for patients from admission to discharge. Monitors individuals’ progress toward desired outcomes through assessments and evaluations. Communicates both in-person and by phone with client, medical providers, attorneys, employers, employees, insurance carriers, etc. Develops and administers education and prevention programs. Develops guidelines for working with patients, healthcare management companies, insurance companies, or other third party payers to determine quality, cost-effective care. Applies all special instructions required by individual insurance carriers and referral sources. Applies all laws and regulations that apply to the provision of rehabilitation services. Testifies when called upon to do so, to substantiate any casework or reports that may be seen as relevant to hearing involving client. Evaluates outcome of patient care. Prepares reports and other required paperwork as documentation of all casework activities. May arrange referrals, consultations, therapeutic services, and confers with other specialists on course of care and treatment.

Nurse Case Manager

Coordinates managed care cases of plan members admitted to the provider plan facilities and/or members utilizing services outside the provider plan facilities. Case coordination typically includes prospective and retrospective review that includes, but is not limited to, prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for patients from admission to discharge. This managed care position is typically filled by a registered nurse with current State license.: Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs. May arrange referrals, consultations, therapeutic services, and confer with other specialists on course of care and treatment.

Medical Nurse Case Manager

Inpatient Nurse Case Manager

Coordinates the delivery of healthcare and social services to the inpatient population while balancing individually identified patient and family, medical, and psychosocial needs with cost-effective and available resources. Manages the inpatient hospital stay of a caseload of patients through coordination with physicians, social workers, nursing staff, and other health professionals. Reports to the Nurse Manager of assigned unit.: Performs utilization review and collaborates with the care team to formulate the discharge plan. Implements a plan of care utilizing approved clinical guidelines to transition and provide continuity of care for the patient to an appropriate lower level of care in collaboration with the hospitalist/physician member team, acute or skilled facility staff, ambulatory care team, and the patient and/or patient's representative from admission through discharge. Interfaces with physicians, nursing staff, and other members of the multidisciplinary and medical records coding staff to ensure appropriate reimbursement is received. Determines medical necessity for admission and continued stay according to specific criteria and regulations in accordance with the Utilization Review Plan. Conducts daily/concurrent reviews of charts to rectify any deviation from compliance. Educates staff, physicians, and other members of the multi-disciplinary team on documentation for compliance. Identifies consistent clinical and operational problem areas and facilitates resolutions through participation in the performance improvement process. Acts as liaison for the management and communication of information with the insurance/managed care companies of the assigned patient population.

Ambulatory Nurse Case Manager

Works with enrollee's providers and caregivers in a health plan to provide intensive, comprehensive case management and increase efficient utilization of services. Typically requires Registered Nurse licensure with patient care experience. Certified Case Manager (CCM) certification may be required.: Identifies chronic or catastrophic cases through the case management process and initiates intensive case management according to program guidelines. Evaluates the medical necessity for elective inpatient hospital admission, and authorizes the admission along with the estimated length of stay. Consults with Inpatient Nurse Case Managers regarding existing case management enrollees as well as potential case management enrollees. Screens for the medical necessity of outpatient procedures, home medical equipment, medications, and any other service that requires precertification. Retrospectively reviews medical admission of categories of diseases and procedures. Makes recommendations for standards of care as necessary. Identifies quality indicators through the case management process. May direct abnormal lengths of stay to the Medical Director or Associate Medical Director. May perform on-site reviews for back-up to an Inpatient Nurse Case Manager.

Medicare Nurse Case Manager

Plans, directs, implements, and evaluates appropriate healthcare services for Medicare patients in conjunction with Physician's treatment plan to ensure that cost effective, quality care is provided. Typically requires licensure as a Registered Nurse with three years of relevant nursing and medical case management experience. Certification as a Case Manager or professional certification in a clinical specialty may also be required.: Coordinates cases that normally include prospective and retrospective review and prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for Medicare patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs for Medicare patients. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. May arrange referrals, consultations, therapeutic services, and confer with other specialists on course of care and treatment. May negotiate fees with providers of medical care, agencies, and outside vendors to achieve maximum cost effectiveness.

Nurse Case Manager (Mentor)

Plans, directs, implements and evaluates appropriate healthcare services in conjunction with the physician treatment plan to ensure that cost effective, quality care is provided.: Case coordination normally includes prospective and retrospective review which includes prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. Authorizes initiation of medical case management. This position typically requires a licensed Registered Nurse with a minimum of five years of relevant nursing and medical case management experience. Certification as a case manager or professional certification in a clinical specialty may also be required. May arrange referrals, consultations, therapeutic services, and confer with other specialist on course of care and treatment. May negotiate fees with providers of medical care, agencies and outside vendors to achieve maximum cost effectiveness. May provide guidance to less experienced case managers.

Field Manager

Conducts on-site quality assurance inspections and on-the-spot performance evaluations and observations to ensure safety, profitability, customer satisfaction, and compliance with company policies and standard operating procedures.: Creates work schedules and maintains proper accounting of field staff productivity. Conducts in-service training and/or initiates formal or informal counseling for field staff to improve overall performance, correct identified deficiencies, and address disciplinary issues. Prepares and submits detailed site inspection reports to management documenting all post visits and training or counseling conducted. Prepares written performance warnings documenting observed violations of company standards of conduct. Communicates with management and Human Resources to implement consistent counseling and disciplinary policies and procedures. Participates with Operations management in identification of service issues, equipment needs, or field procedural issues and suggests corrective action. Conducts general physical security inspection during site visits and documents any deficiencies noted on the site inspection report. Plans inspection routes and timetables. Trains and prepares for emergency situations at site. Responds to emergency situations at field locations and assists site staff as needed. Prepares detailed incident reports for all emergencies or serious incidents. Ensures that vehicles are inspected during each shift and maintenance issues are addressed. May operate a company or customer motor vehicle as directed.

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