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This Position Is Responsible For Performing A Variety Of Functions And Is A Single Source Of Contact For Members, Health Care Personnel And All Other Entities Involved In Managing Care. Identifies Alternate Treatment Programs; Consults With Physicians, Providers, Members, And Other Resources To Evaluate Options And Services Required To Meet An Individual *S Health Needs. Promotes Quality And Cost Effective Outcomes; And Serves As Liaison To Physicians And Members. Other Functions Also Include Determining Member Assignment Of Treatment, And Pre-Admission/Post-Discharge Counseling For An Acute Condition. Establish Relationship With The Member. Handle Immediate Post Discharge Follow-Up Or Until All Short Term Care Needs Are Met. Provide Education/Local Resource Information And Encourage Member (Self) Education. Functioning In A Clinical Care Advisory Role, Assesses Members For Wellness Education And Disease Management, Introduces Members To Our Website Tools, Educates Members Regarding Wellness And Specific Conditions, And Facilitates The Coordination Of Care For Identified Members. Provide Oversight To Holistic Health Coordinators. JOB REQUIREMENTS: * Registered Nurse (RN) with current, valid, unrestricted license in state of operations * 2 years of clinical practice experience of direct clinical care to the customer * 1 year of experience in care management/condition management in a health insurance/managed care setting * PC proficiency to include Word, Excel, Lotus Notes and database experience * Clear and concise verbal and written communication skills * Familiarity of ancillary services including HHC, SNF, Hospice, etc * Analytical skills * Decision making skills and sound clinical judgment to provide oversight of other staff PREFERRED JOB REQUIREMENTS: * Experience in managing complex or catastrophic health cases * Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management) * Working toward or completion of CCM/CCP/CDE/MCG certification or Advanced degree * Knowledge of Milliman Guidelines or similar clinical guidelines * Knowledge of medical management policies and procedures Additional job description: 1. Consult with physician, providers, members, and other resources, as appropriate, to assess, plan, facilitate implementation, coordinate, monitor, and evaluate options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes. 2. Develop alternate plans and assist members/providers to navigate the health care system optimizing benefits. Refer care options to network providers. 3. Perform discharge care coordination, episodic case management and pre-admission/post discharge counseling and identification of alternate treatment options. Consult with physicians, coordinators, and facility discharge planners to determine other resources and appropriate disposition of such cases. Provide education, counseling and referral to other resources to minimize re-admissions and emergency room episodes. 4. Perform additional ongoing functions to support the member in the transition of care process including consulting with physicians, providers, members, and other resources, as appropriate, to assess, plan, facilitate implementation, coordinate, monitor and evaluate options and services required to meet an individual’s acute health needs, using communication and available resources to promote quality health outcomes. 5. Contact members and attempt to engage them in a condition specific education program based on condition specific National Standards of Care. Educate members regarding wellness and specific conditions based on National Standards of Care. 6. Provide supplemental educational materials to member as required. 7. Collaborate with the Medical Directors, as necessary. 8. Refer members to other resources – community based organizations, transportation, home health, etc. 9. Provide clinical oversight to Holistic Health Coordinators by providing clinical advisory/consultative information on review of files during daily meetings. 10. Maintain licensure and maintain and enhance knowledge for designated area of licensure and regulatory standards by attending seminars, training sessions, etc. 11. Practice within the scope of licensure in accordance with URAC and NCQA accreditation standards and with the applicable state Nurse Practice Act. 12. Communicate and interact effectively and professionally with co-workers, management, customers, etc. 13. Comply with HIPPA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. 14. Maintain complete confidentiality of company business. 15. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects are required or requested.

JOB REQUIREMENTS: * Registered Nurse (RN) with current, valid, unrestricted license in state of operations * 2 years of clinical practice experience of direct clinical care to the customer * 1 year of experience in care management/condition management in a health insurance/managed care setting * PC proficiency to include Word, Excel, Lotus Notes and database experience * Clear and concise verbal and written communication skills * Familiarity of ancillary services including HHC, SNF, Hospice, etc * Analytical skills * Decision making skills and sound clinical judgment to provide oversight of other staff PREFERRED JOB REQUIREMENTS: * Experience in managing complex or catastrophic health cases * Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management) * Working toward or completion of CCM/CCP/CDE/MCG certification or Advanced degree * Knowledge of Milliman Guidelines or similar clinical guidelines * Knowledge of medical management policies and procedures

Compensation: $60,300.00 - $133,400.00

Exact compensation may vary based on skills, experience, and location

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

To learn more about available benefits, please click https://careers.hcsc.com/totalrewards