About this job
We are seeking candidates who are interested in a temporary position of 30- 40 hours per week. The position involves a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes for children with special needs as mandated by the MAA contract.
The RN Case Manager, Children with Special Needs spends approximately 80\% of the work time completing member assessments, creating member-specific care plans, attending patient- specific meetings, and managing member care coordination. The RN Case Manager, Children with Special Needs, spends the remaining 20\% of the work time preparing and reviewing completed reports, participating in case rounds, and facilitating Team interaction and workflow among each other and coordination with Behavioral Health staff, the Social Worker, and other areas as necessary.
MINIMUM POSITION REQUIREMENTS
Graduate of accredited school of professional nursing
Bachelor’s degree in nursing (BSN) preferred
Master of Science Nursing (MSN) or master of Public Health Degree (MPH) a plus
Knowledge of applicable state, federal guidelines, third party regulations and standards for Medicaid, Medicare, NCQA, URAC; CMSA preferred. .
Prior experience working with Medicaid, Medicare recipients or underserved population strongly desired.
REQUIRED CREDENTIALS, LICENSURES, OR CERTIFICATION:
Registered Nurse with current, valid unrestricted licensure to practice nursing in the District of Columbia, Maryland or Virginia, a must.
Master’s Degree (MSN, MBA or MPH) a plus
Previous working experience and competency utilizing InterQual criteria required.
Must possess working knowledge of utilization review standards and be knowledgeable regarding medical terminology and ICD-9 CM coding.
Certified Professional Utilization Review / Management Certification (CPUR, / CPUM and / or CCM) preferred.
WORK BACKGROUND AND EXPERIENCE:
Five (5) years clinical management experience in the nursing areas of Utilization Management, Quality Management, Risk Financing experience in a managed care environment required.
Registered Nurse with Neonatal Intensive Care or Pediatric acute care experience.
Demonstrated analytical / critical thinking and strategic planning skills required
Five (5) years of healthcare management experience at a supervisory or managerial level
Comprehensive knowledge of the care continuum, alternate environments of care, and the business aspects of risk contracting and health plan management
Minimum five (5) years working knowledge of state and federal government program regulations, relating to care and treatment of Children with Special Needs.
Working knowledge of accreditation standards such as NCQA, URAC and CMSA
Experience with Children with Special Needs programs preferred
Current license to practice as a registered nurse in the District of Columbia required.
Knowledge of, and experience with public and private programs for Children with Special Needs. Experience in the District of Columbia a preference.
Able to evaluate and develop plans of care that entails the medical, psychosocial needs.
Able to work independently, with minimal supervision.
Organized, able to handle multiple activities with changing priorities.
Excellent written and verbal communication, with computer skills including.
Able to work with people with diverse backgrounds, both members and providers.
· Competent in computer skills including MS Word, Excel, and Access.
POSITION DUTIES AND RESPONSIBILITIES
· The coordination of care for children identified as having special needs.
Act as Client’s liaison to MAA and other public and private programs to coordinate care for children with special needs.
Coordinates the CAHMI survey and evaluation program working with internal and external resources to insure children age 0-18 are assessed, evaluated, and referred for appropriate disease or case management and care coordination.
Prepare reports as required for internal and external use that are timely, thorough and accurate.
Evaluation of the members needs, design in conjunction with other healthcare professionals a plan for meeting those needs in the most cost effective way possible while insuring quality is met working within the parameters of available benefits.
Coordinate, evaluate, and monitor care services from all care providers whether PAR or non-PAR.
Negotiate appropriate reimbursement for services and equipment for non-PAR providers.
Maintain accurate, timely, and hold confidential all personal health information.
Approve medically necessary services and equipment that require prior authorization for reimbursement utilizing the appropriate medical criteria.
Prepare cases for services not meeting medical necessity criteria for referral to the Medical Director for review and final determination within the required review timeframes.
Provide notification of review determinations within the appropriate timeframes following policies and procedures.
Participate in case rounds and other care management meetings, presenting clinical information on current cases, identifying potential cases for case management and service review, and coordinating care with other Medical Management team members.
Participate in special projects as needed and assigned.
Performs peer review monthly audits of team members.
Evaluates effectiveness of the programs and makes recommendations for program modification and workflow as appropriate.
Coordinates and communicates provider issues with provider relations.
Ensures timely filing and scanning of cases.
Facilitation of Children with Special Needs Team interaction and workflow
COMPETENCE AND SKILLS:
Position requires abilities to manage working relationships of staff within “Special Programs” as well as the technical aspects of work required to meet the functional responsibilities of the “Special Programs” staff. Responsibilities require that the manager possess strong communication skills, problem solving, organizational and interpersonal skills. Requires leadership and management skills to lead and motivate clinical and non-clinical personnel. Also requires self-motivation, the ability to accurately assess variations from the expected and conduct activities to detect the reason(s) of the variation. Strong project management skills and the ability to lead diverse teams are required. Creative thinking as well as ability to resolve opportunities, using the least resources necessary is a desired attribute. Manager must be able to work with a multiple external entities. Must also advocate for staff when appropriate. Basic data analysis skills are helpful.