FEP Case Management – Nurse, Senior Position Available In Western Connecticut, Connecticut

Job Description:

Your Role Work schedule is Mon-Fri 10am- 7pm The FederalEmployee Program (FEP) team performs integrated case management(CM) and disease management (DM) activities demonstrating clinicaljudgment and independent analysis, collaborating with members andthose involved with members’ care including clinical nurses andtreating physicians. The Regional Registered Nurse Case Managerwill report to the FEP Care Management Department Manager. In thisrole you will determine, develop, and implement a plan of carebased on accurate and comprehensive assessment of the member’sneeds Your Work In this role, you will: Coordinate care for lowerlevel of care such Skilled Nursing Facility, Home Health, HomeInfusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, andother community program as appropriate Perform effective dischargeplanning and collaborate with member’s support system and healthcare professionals involved in the continuum of care Providesdisease management education on core chronic conditions (Diabetes,Heart Failure, COPD, Asthma and Coronary Artery Disease). Outreachto members with HEDIS Care Gaps to assist with closure Applydetailed knowledge of FEP PPO and Blue Shield of California’sestablished medical/departmental policies, clinical practiceguidelines, community resources, contracting and community carestandards to each case Research and design treatment/care plans topromote quality of care, cost effective health care services basedon medical necessity complying with contract for each appropriateplan type Provide Referrals to Quality Management (QM), DiseaseManagement (DM) and Appeals and Grievance department (AGD)Recognize the clients right to self-determination as it relates tothe ethical principle of autonomy, including the client/family’sright to make informed choices that may not promote the bestoutcomes, as determined by the healthcare team Design appropriateand fiscally responsible plan of care with targeted interventionsthat enhance quality, access and cost-effective outcomes Initiateand implement appropriate modifications in plan of care to adapt tochanges occurring over time and through various settings Must beable to sit for extended periods of time and read information onone computer screen and apply that information on a second computerscreen to complete documentation Your Knowledge and ExperienceRequires a current CA RN License. Bachelor of Science in Nursing oradvanced degree preferred Certified Case Manager (CCM)Certification or is in process of completing certification wheneligible based on CCM application requirements Requires at least 5years of prior experience in nursing, healthcare or related field 3years managed care experience preferred. Comprehensive knowledge ofcase management, discharge planning, utilization management,disease management and community resources preferred Behavioralhealth, oncology, or OB/NICU/pediatrics experience preferred Strongelectronic clinical documentation skills, independent problemidentification and resolution skills Knowledge of coordination ofcare, prior authorization, level of care and length of staycriteria sets desirable Competent understanding of NCQA and federalregulatory requirements Demonstrate leadership, project managementand program evaluation skills and ability to interact with alllevels including senior management and influence decision-makingDemonstrates professional judgment, and critical thinking, topromote the delivery of quality, cost-effective care. This judgmentis based on medical necessity including intensity of service andseverity of illness within contracted benefits and appropriatelevel of care