Medical/Clinical Policy Writer
CareSource
Salary
💰 $75,000 - $90,000 per year
Job Level
Mid-LevelSenior
About the role
- Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care
- Develop and document a case management care plan in direct collaboration with the beneficiary, family/significant other(s), primary physician and other health care providers
- Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan
- Coordinate and implement activities specified in the care plan to provide optimal benefits coverage and promote continuity of care and integration of services across care transitions
- Monitor and continually evaluate the care plan on a scheduled basis; revise and update in collaboration with beneficiary and health care team
- Initiate care conferences with Medical Director and/or the multidisciplinary care team for challenging cases and expert consultation
- Serve as beneficiary advocate promoting self-determination, informed/shared decision-making, autonomy, and self-advocacy; provide education and support to reinforce self-care management and facilitate access to care
- Identify relevant benefit-related, educational, and health care resources and facilitate coordination with community-based programs and services
- Demonstrate and apply knowledge of comprehensive case management, patient-centered, culturally sensitive care coordination, and management of complex conditions
- Collaborate with beneficiaries, caregivers, providers, multidisciplinary team, and community resources throughout the case management process
- Be familiar with and understand the scope of professional licensure and carry out case management activities consistent with that scope
- Participate in ongoing training and professional development to build and maintain case management competencies and evidence-based practices
- Maintain CEUs and required licenses; willing to obtain and maintain additional licenses as needed
- Conduct case management activities consistently with professional standards of practice and applicable policies and procedures
- Participate in regular team conferences and meetings and document appropriate clinical information timely, accurately, and concisely
- Maintain working knowledge of and adhere to applicable federal and state regulations including patient confidentiality, release of information, and HIPAA
- Work schedule Monday - Friday 5 days x 8 hours; remote telephonic shift times aligned to state of residence and time zone (PT/MT/CT/ET)
Requirements
- Current, unrestricted RN license in state of residence with multi-state privileges (an active compact state license)
- Must hold United States citizenship status
- Ability to obtain Security Clearance required; Current DOD Security Clearance preferred
- Associate or bachelor's degree in nursing from an accredited institution; Bachelor’s degree preferred
- 5+ years of clinical RN experience in direct patient care
- Knowledge of case management practices and patient-centered care concepts
- Proficiency in Microsoft Office, mobile technologies and navigating multiple applications
- Ability to adapt to changing priorities
- 1+ years of prior case management experience (preferred)
- Case Management Certification highly desirable (CCM preferred)
- Experience working in an NCQA accredited case management program (preferred)
- Experience as a telephonic case manager at a health plan highly desirable
- Excellent organizational and prioritization skills (preferred)
- Strong communication skills (verbal, written, presentation, interpersonal) (preferred)
- Ability to work independently and collaboratively (preferred)
- Critical thinking and clinical problem-solving skills (preferred)
- Appreciation for cultural diversity and health and digital literacy issues (preferred)
- Professional demeanor and excellent customer service skills (preferred)
- Ability to work independently in a home office environment (preferred)
- Maintain CEUs as required by applicable State Board(s) of Nursing and required certifications; must be willing to obtain and maintain additional licenses as required to meet business needs
