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Nurse Case Management Senior Analyst
Ref No.: 21-00350
Location: McAllen, Texas
Title: Nurse Case Management Senior Analyst (TX)
Location: McAllen, TX - REMOTE
Duration: 02/22/2021 through 05/01/2021 with opportunity for extension! 
Schedule: Monday-Friday 8 am to 5 pm (CST)


Job Description:
Under general supervision of the Director of Clinical Programs and the Manager Complex Case Management, the RN Complex Nurse case manager is responsible for assessing members with multiple and complex medical conditions who need post discharge care transition and or short term complex case management, Conducts a person centered assessment and  identifies barriers to care, develops a  person centered My Health Coach Plan, conducts self-management education, ongoing monitoring of signs and symptoms and care coordination and refers to appropriate community services and healthplan services and benefits to minimize barriers to care and the risk or unnecessary admission, readmission or emergency room utilization . 

Case Manager Primary Duties & Responsibilities
  • Prepares for member outreach by reviewing available medical history including known chronic conditions, whether or not the member is receiving routine chronic and preventive health care, if there are identified medication adherence issues and gaps in care based on predictive modeling reports, services that are in place and reviewing Service Coordination notes and HRA. 
  • Conducts Telephonic assessments to identify barriers to care such as the need for LTSS and or Waiver level services, equipment, medication management, self-care education and monitoring and establishing a medical home, community services and housing, establishing a medical home for routine preventive and chronic care management. 
  • Effectively manages a case load of 60 – 100 members and conducts outreach based on departmental policies and as often as necessary to effectively bring about stabilization of medical health and improved quality of care.
  • Assists in the identification of member health education needs and monitors current clinical status by conducting assessments using approved assessment tools, identifying the need for physician or other intervention to prevent avoidable admission or readmission.
  • Works with members to identify and set personalized health improvement plans and goals and support members in achieving those goals Assesses the member’s readiness to change and implements actions to assist members in moving through stages of change to reach their goals
  • Collaborates with team members such as Clinical pharmacist, Service coordinators, Medical Director, ancillary service providers and member's medical home provider and treating specialist as well as other case managers in order to eliminate or mitigate barriers . Works with members  and treating physicians on opportunities to close gaps of care and to improve the member’s  overall health status
  • Collaborates with Cigna HealthSpring Star+Plus UM  discharge case managers to facilitate effective communication for members with multiple and complex medical conditions at higher risk of readmission assigned for post discharge transitions of care for the purposes of assisting with community resources, DME providers, referrals, housing and other related duties.  Conducts post discharge assessments for assigned members in accordance with policy and refers members to DM Managers who are in need of a face to face visit due to inability to locate the member after multiple attempts, when successful interaction via telephone with the member has not been successful and when clinically indicated to determine scope of problem and environmental and social contributing factor
  • Collaborates with the member/family, physician, and health care providers/suppliers to discuss and prioritize the plan of care and prescribed treatment plan in accordance with evidenced based medicine and identified long and short term goal
  • Outreaches to obtain clinical records as necessary to establish the prescribed treatment plan, obtain results of tests and x-rays and other necessary clinical information for the purpose of treatment planning and operations.
  • Develops, monitors, and evaluates the My Health Coach Plan of Care, extends, revises or closes the plan of care according to Interdisciplinary care team recommendations and communicates case management decisions.  Communicates with the Service Coordinator, Disease Management Case Manager in preparation of transitioning from complex case management.
  • Consults with BH team members in cases where a member’s behavioral health or emotional issues are impacting their ability to set and/or achieve goals
  • Understands and follows policies and procedures, completes documentation of interactions and interventions of assigned members in the QNXT case record  and SC Web app or other systems as it applies using approved note templates, produces and submit reports in a timely manner and in accordance with workflows and policies
  • Actively participates in interdisciplinary care teams; assures appropriate documentation in QNXT and SC Webapp and that My Health Coach Plans are current prior to scheduled ICT meetings.
Minimum Requirements: 
  • Current licensure as a Registered Nurse (RN)   
  • Three or more years of clinical experience and two or more years of experience in case management and knowledge of chronic conditions
  • Proficiency in Microsoft Office Word, Excel and windows based systems. 
  •  Excellent written and verbal skills in communicating with Members, Caregivers and providers 
Preferred Requirements:
  • Certification as Case Manager or will agree to become certified within one year of hire.  
  • Previous STAR+PLUS Medicaid and or Medicare Managed Care experience.
  • Prior experience and knowledge of making referrals to community resource organizations.
  • Three or more years’ experience in clinical case management of members with multiple  and complex chronic conditions
  • Experience in telephonic counseling/coaching preferred.
  • Good problem solving skills and the ability to triage based on severity
  • Excellent interpersonal skills and the ability to work in a team environment. 
  • Bilingual English-Spanish Highly Preferred.