The Dedicated Case Manager Nurse 2 assesses and evaluates member's needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The Dedicated Case Manager Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Dedicated Case Manager Nurse 2 employs a variety of strategies, approaches, and techniques to manage a member's physical, environmental, and psycho-social health issues. Identifies and resolves barriers that hinder effective care. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
The DCM program involves a wide range of activities, depending on the needs and goals of the provider practice. Taken together, these form a coherent set of activities that are carried out or facilitated by DCM’s. They include, but aren’t limited to, the following:
- Engaged Provider Office(s) based assignment or WAH with regularly established communication patterns with providers on path to value arrangement
- Educate providers on gap closing opportunities and encourage/support gaps closure
- Develop, enhance and maintain provider clinical relationship across identified membership.
- Collaborate with physicians/practice staff to encourage and influence member participation in clinical programs and completion of HEDIS gaps.
- Conduct Provider education on clinical program referral management and processes
- Collaborate across Humana organization with clinicians, provider relations, coder, etc. for identified opportunities and issue resolution.
- Identify medication usage/pharmacy opportunities and confer with Market Clinical Pharmacy Lead.
- Collaborate with provider office to ensure members post discharge follow up visit/s scheduled and completed within one week of discharge.
- Facilitate exchange of information between providers e.g. PCP/Specialist
- Coordinate Chart audits/HEDIS chart chase (EMR/hard copy) and information to close gaps
- Serve as liaison between provider and insurer to resolve issues
- Meet with members for education on Humana specific programs at provider practice
- Review and / or document on multiple internal/external systems e.g. EMR, CGX2.0, Rosalind, Care Book
- RN – direct managed care experience in UM and/or CM, Certified Case Manager (CCM) (applies to RN designation) preferred
- Active license in the state in which nurse is required to practice with unencumbered ability to be licensed in multiple states
- Experience working with the adult population
- Knowledge of community health and social service agencies and additional community resources
- Exceptional communication and interpersonal skills with the ability to quickly build rapport
- Ability to work with minimal supervision within the role and scope
- Ability to use a variety of electronic information applications/software programs including electronic medical records
- Intermediate to Advanced computer skills and experience with Microsoft Word, Outlook, and Excel and PowerPoint
- Excellent keyboard and web navigation skills
- Ability to work a full-time (40 hours minimum) flexible work schedule
- This role is a part of Humana's Driver Safety program and therefore requires and individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,00 limits
- Must have a separate room with a locked door that can be used as a home office to ensure continuous privacy while you work
- Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home systems if 5Mx1M
- This role is considered patient facing and is part of Humana's Clinical Onsite Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
- Valid driver's license, car insurance, and access to an automobile
- Ability to work cohesively with multidisciplinary teams as well as an independent contributor
- Excellent written and verbal communication skills
- Ability to solve problems and resolve clinical and social issues arising with members, members’ family/care giver and healthcare providers effectively and efficiently
- Proven examples of responsibility and accountability
- Medicare/Medicaid experience
- Knowledge of the health insurance industry
- CMS Stars/performance measures/HEDIS knowledge and experience
- Experience with health promotion, coaching and wellness
- Bilingual — English, Spanish
- Certification in Case Management
- Motivational Interviewing Certification and/or knowledge
This role requires at least 4 days per week in multiple physician practices and 1 day from home. Some travel required in the Central Alabama Region. Mileage is reimbursed according
to Company Policy. There will be 3-4 weeks orientation out of state training.
Scheduled Weekly Hours