Utilization Management Nurse

JOB SUMMARY

Under the direction of the Director of Care Management, the RN Care Manager is responsible for managing high-risk, chronic illness members to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The RN Care Manager will formulate and implement a care management plan that addresses the members identified needs by assessing issues, resources, and care goals. The RN Care Manager will advocate for the member and support the member in navigating the health care system. Additionally, the RN Care Manager will work collaboratively with the interdisciplinary team and members PCP / Health Care Team to identify and support the achievement of the members short term and long-term health goals. HTA’s Care Management model is to provide longitudinal care management for identified members. Based on the RN’s work experience in nursing and knowledge of the health care system, the aims are to provide education and resources to members to ultimately reduce preventable emergency room visits and hospitalizations and re-admissions.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This position must be able to:

Collaborates with providers and practice staff in identifying appropriate members for care management, utilizing established Care Management criteria.

Performs initial and periodic holistic assessments for identified care managed population. This includes physical and psychological concerns for members as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the member. Prioritize members according to intensity, need, and required to follow-up.

Formulates and implements a care management plan that addresses the member’s identified needs by assessing the member/family needs, issues, resources, and care goals; determining the choices available to individual members; and educating the patient/family on the choices available to meet their goals.

Establishes a care management plan that is mutually agreed upon by the health care team and the member/family. Plans specific mutual self-management goals and objectives, and interventions with the members that are action-oriented.

Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals. Monitors and evaluates the member's progress at prescribed, minimal intervals.

EDUCATION AND EXPERIENCE

Education:

• Associate Degree in Nursing

Required Experience:

• Five years of nursing-related care experience and/ or home care experience combined.
• Registered Nurse licensed in North Carolina or a Compact state. 
•  Current NC RN licensure in good standing

Preferred Experience:

• BSN or Advanced Degree in Nursing
• Case Management Certification is desirable.
• Case Management, Care Management, Telephonic Case Management, and/or Disease Management experience
• Advanced clinical knowledge.
• Skills related to physical assessment, wound care, blood pressure monitoring, CBG checks, and Foley Cath care. Clinical knowledge and ability to educate clients of all ages about the following core disease management issues: Diabetes, Hypertension, Hyperlipidemia, CAD, Asthma, COPD, and renal disease required. (This is not intended to be an inclusive list of all conditions.)

Other Requirements:

• Annual Flu Vaccine

KNOWLEDGE, SKILLS, AND ABILITIES

Required Competencies:

• Knowledge of care management concepts along the continuum
• Knowledge of Medicare benefits
• Experience and ability to use Microsoft Office products and word-processing software on a daily basis
• Excellent written, verbal, and listening communication abilities. Communicates appropriately and clearly to members, coworkers, and providers.
• Ability to manage conflict, stress, and multiple simultaneous work demands in an effective and professional manner.
• Ability to successfully articulate the process of attaining goals and outcomes of care management
• Ability to apply clinical knowledge and experience in a care management role
• Ability to engage and collaborate with the member and significant others in the care management process
• Ability to care manage diverse populations without applying one’s own personal values
• Ability to work with minimal supervision within the nursing scope of practice
• Ability to think critically and analytically, and work with minimal supervision.
• Ability to evaluate and appropriately respond to verbal and non-verbal communication from patients in diverse stages of development
• Ability to use good judgment to protect personal safety while performing duties

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.

ABOUT HEALTHTEAM ADVANTAGE

HealthTeam Advantage is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 33 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com