RN, Care Manager

Remote Opportunity

Bilingual Spanish Speaking required

Schedule: Monday - Friday 8:00 am - 5:00 pm CST

PRIMARY FUNCTION

Assist in the development, implementation, and operations of a comprehensive Care Management program to distinguish Pediatric Associates in the market based on demonstrating health care quality, efficiency and interconnectivity for patient care management and coordination in support of the mission, core values, goals, and objectives of Pediatric Associates.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This list may not include all the duties that may be assigned.

1. Administers Pediatric Associates Care Management program as it relates to population management initiatives, regulatory compliance, utilization management, discharge/transition planning, and payer relations, and program and staff development.
2. Make determination whether a patient needs care and if so, what kind of care. This role will be responsible for providing care advice and directing the patient to the correct specialist, provider, or hospital.
3. Implements and monitors the case management program focused on population health management.
4. Develops and maintains an integrated clinical care management model that fosters appropriate levels of care and maximizes reimbursement/cost savings.
5. Administers care management partnerships with commercial payers and other entities.
6. Establish innovative relationships with payers and employers that promote value and expand market share.
7. Serves as liaison between across the revenue cycle management departments to coordinate effective information flow related to payer contracts and reimbursement.
8. Informs patients regarding general preventative care practices as well as individualized care plans.
9. May keep track of and/or update patients' records, especially electronic records, and must keep current with computer technology, software, security measures, and legislation regarding patient privacy and other issues.
10. Monitors changes in a patient’s status and subsequent alterations to the care plan.
11. Helps implement measures to improve patient care.
12. Reviews utilization practices and facilitates positive changes to patient behaviors regarding their medical care.

QUALIFICATIONS

EDUCATION: Minimum associate degree in nursing required; bachelor’s degree preferred

EXPERIENCE: A minimum of 3 years of experience in care management, practice administration, and/or managed care required. A minimum of 5 years is preferred.

LICENSURE / CERTIFICATION: Registered Nurse (RN) license required.

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of medical billing and health records maintenance preferred.
• Significant knowledge of population health management and operational issues related to payers and networks, physician groups, and health insurance benefit plan designs preferred.
• Knowledge of ICD-10, ICD- 9, CPT and HCPCS coding required.
• Must have excellent interpersonal and communication skills.
• Must have excellent decision making and problem-solving skills.
• Must be detail oriented and have good analytical skills.
• Knowledge of laws governing the protection of patients’ private health information.
• Knowledge of emerging public health issues, health care inequities, health care financing, and health systems.
• Efficient in handling high volume datasets with accuracy, thinking dynamically to solve complex reporting queries, proficiency with MS Office products including Advanced Excel skills & a minimum of beginner/intermediate MS Access skills.

TYPICAL WORKING CONDITIONS

• Remote/telework.
• The position involves high & frequent call volumes.
• Environment requires ability to multi-task, communicate clearly & concise, data entry for extended period of times.
• Will require sitting for long periods of time.

OTHER PHYSICAL REQUIREMENTS

• Vision
• Sense of sound
• Sense of touch

PERFORMANCE REQUIREMENTS

Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI (Protected Health Information) in accordance with organizational policy, Federal, State, and local regulations.