Case Manager I (RN) - Patient Review and Coordination (PRC) Program

Job Summary

Responsible for the operational delivery of the plan’s case management and PRC program. Provides case management services for CHPW members with short term, long term, stable, unstable, and predictable course of illness, and/or highly complex medical/behavioral and social conditions.

The goal is to improve members' quality of life and ensure cost-effective outcomes by using internal and community-based resources.

The Case Manager level will be determined by the hiring manager based on education, previous experience, and demonstrated leadership skills.

The PRC RN Case Manager is responsible for evaluating members’ medical and behavioral health histories to determine eligibility for enrollment in the PRC program. This role also includes providing telephonic case management services to members with acute, chronic, or complex healthcare needs.

To be successful in this role, you:

• Have a Bachelor’s degree in nursing, or a master’s degree in social work and/or related behavior health field (preferred)
• Possess Current, unrestricted license in the State of Washington as a registered nurse (RN) (required) OR
• Current, unrestricted license in the State of Washington as a Social Worker (LSWAA, LSWAIC) (required), OR
• Current, unrestricted license in the State of Washington as a Mental Health Counselor (LMHC), Mental Health Professional (LMHP), or Marriage and Family Therapist (LMFT) (required)
• Have a minimum of one (1) year case management, home health or discharge planning experience; or a combination of education and experience which provides an equivalent background required OR
• Have a minimum of one (1) year facility-based medical or behavioral health experience and/or outpatient psychiatric and substance abuse/substance abuse disorder treatment experience, required; or equivalent combination of education and experience and/or working with children and families. Experience with those who have disabilities and knowledge of Child and Families Services
• Have a minimum three (3) years of clinical experience in an acute care and/or outpatient setting (required)
• Experience and proficiency with Microsoft Office products
• Possess a Case Management Certification (preferred)
• Have Bilingual abilities (preferred)

Essential functions and Roles and Responsibilities:

Examples listed below are not necessarily exhaustive and may be revised by the employer.

• Advocates on behalf of members and facilitates coordination of resources required to help members reach optimum functional levels and autonomy within the constraints of their disease conditions.
• Works within a multi-functional team to connect with providers, members, caregivers, contracted vendors, community resources, and health plan partners to assess the member's health status, identify care needs and ensure access to appropriate services to achieve positive health outcomes.
• Assesses, evaluates, plans, implements, and documents care of members within the organization’s clinical database system, in accordance with organizational policies and procedures.
• Responsible for the assessment of members, including identifying and coordinating access to the appropriate level of care and treatment. Uses the assessment information to assign the appropriate risk and complexity level, and create and document a care plan in coordination with the member, family and health team input.
• Initiates a plan of care based on member-specific needs, assessment data and the medical/behavioral plan of care. Goals for members are measurable and developed in conjunction with the patient/family to improve quality of life.
• Plans care in collaboration with members of the multidisciplinary team, and considers the physical, behavioral, cultural, psychosocial, spiritual, age specific and educational needs of the member in the plan of care.
• Reviews and revises the plan of care with the interdisciplinary care team to reflect changing member needs based on evaluation of the members’ status, and/or as a result of reassessment.
• Implements the plan of care through direct member care, coordination, and delegation of the activities of the health care team. Promotes continuity of care by accurately and completely communicating to health care team the status of members for whom care is provided. Engages community resources where applicable.
• Conducts interdisciplinary care team meetings with the member/family to assess care plan and recommend adjustments as indicated.
• Continuously evaluate members’ progress towards goals, identify potential barriers to attaining goals and expected outcomes in collaboration with other health care team members.
• Documents all case activity using the CHPW care management