Care Management Nurse RN

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs: ' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women ' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR ' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions. ' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve. Community is accredited by URAC for its health plan operations.

We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers. JOB

Care Manager will manage Community Health Choice (Community) members with chronic disease and medically complicated needs through comprehensive evaluation and through coordination of Community resources. The Care Manager will participate as a team member in Community Care Management programs, which are designed to assist members with chronic diseases in self-management skills. Care Manager will work collaboratively with utilization review, member services and the quality improvement department.

JOB SPECIFICATIONS AND CORE COMPETENCIES Caseload Management - Documents case status and reviews dates accurately in care management module. Caseload activities completed timely per review dates assigned or within authorization time frame turnaround time requirements. Initiates/receives member calls related to Program need for assessments and follow-up contacts.

Available as clinical oversight and resource for the LVN Care Management Specialist. Initial Intervention - Identification and contact potential members for any of the Care Management Programs within the program time frame. Perform initial assessment of identified members for Care Management Services within the program time frame and document in care management module.

Complete Risk Stratification on enrolled members in CM Programs within the program time frame and document Contact providers of enrolled members within the CM program specification. Develop Care Management action plans for members within the Care Management Programs in collaboration with members and providers within the program time frame. Identify applicable educational materials/resources and provide for members in welcome packet.

Obtain and review clinical data, labs, medication history as indicated. Review authorization requests for medical necessity and process per Medical Affairs UM directives. Initiate referrals as indicated (i.e. to Behavioral Health, Complex Case Management, Community Health Worker, etc.) Ongoing Interventions - Record all Care Management activities and contacts within the Care Management Module on a routine and timely basis within the program time frame.

Members follow up contacts completed per program guidelines and/or as documented in action plan as next review date. Review and update Care Management Action plans as warranted and in collaboration with the provider and member. Provide ongoing education to members regarding self-management of disease process.

Monitor events and outcomes of members within the Care Management Program in relation to the action plans. Notify provider of member's progress or completion of goals. Quality/Process Improvement - Works collaboratively with Team Leader, Manager and Director to recommend design, redesign or enhancement to program descriptions and/or supporting materials.

Participation in member events, member educational events and health fairs in collaboration with CHC outreach staff. Participates in team meetings and provides recommendations for process improvement opportunities. Demonstrates knowledge of program requirements and disease process Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans.

Other duties as assigned

Education/Specialized Training/Licensure: Associate's Degree required. RN, current Texas License CCM required or must receive within 18 months of employment required. Bachelors Degree preferred.

Work Experience (Years and Area): Three (3) years of clinical experience Two (2) years or more of MCO Experience Software Proficiencies: Microsoft Office (Word, Excel, Outlook).