Triage Case Management Nurse (RN) - Virtual Care Center
Your Job Summary:
The Case Management Triage RN is responsible advocating and facilitating health management decisions and lifestyle choices for the member. The focus of these activities is to expedite necessary medical services, and triage to proactive case coordination initiating a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health needs and education, utilizing plan benefits and community resources. The triage process will evaluate and facilitate the need for care management, disease management or wellness coaching. Additional responsibilities include member benefit management, redirection of services, individual out-of-network contracting for specialized services, appropriateness review, concurrent review, care management screening, transition of care assistance, new/investigational technology review, and timely discharge facilitation and follow-up. The focus of this position is the triage and initial care coordination of pediatric members, children with special needs, and those enrolled in the Texas STAR+PLUS program, primarily from inbound member calls.
EXCELLENT BENEFITS AND HIGHLY COMPETITIVE SALARY OFFERED!
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members. The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.
Requires valid, unrestricted state Registered Nurses (R.N.) license in multiple states - all 50 states is ideal.
Bachelor of Science in Nursing (BSN), or related field, is preferred.
Certification in Case Management (CCM) is a plus.
Roughly 3-5 years acute care clinical nursing experience.
Around 1-3 years’ experience in a Managed Care Organization (Health Plan/HMO/MSO/TPA/IPA/etc).
Telephonic Triage and Pediatric Nursing experience is strongly preferred.
Around 1-3 years’ experience with case management or care coordination; inpatient settings preferred.
Prior experience with the Texas STAR+PLUS program, or similar programs dealing with SSI and disabled children, is preferred.
Experience working with Federal and State assistance programs (Medicare/Medicaid/etc)
Computer literacy (MS Office) and typing skills are necessary.
Prefer prior experience with, CCMS, InterQual or other healthcare databases.
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Bilingual in both English and Spanish is a significant plus.
- Performs telephone triage to assess caller's needs.
- Provides relevant health information to assist callers in making healthcare decisions.
- Establishes and maintains supportive relationships with callers and their families.
- Performs professional assessment of caller's needs with accurate, concise documentation.
- Conducts thorough symptom assessment of caller's situation using established criteria and protocol.
- Utilizes established software, written materials, on-line resources and nursing background to provide callers with appropriate medical information.
- Provides caller with appropriate community resources as necessary.
- Refers more complex issues as needed for consultation.