/ Your Talent. Our Vision. / At Simply Healthcare , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it's a powerful combination. It's the foundation upon which we're creating greater care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care .
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Location : Tampa or Miami, FL
RN Case Manager / RN Clinician - Managed Care Coordinator
Responsible for overall management of member's case within the scope of licensure; provides direction to non-RN clinicians participating in the member's case in accordance with applicable state law and contract; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum. Responsible for performing telephonic or face-to-face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical health, behavioral health, social services and long term services and supports. Additional assessment tools for screening for member needs (i.e. Initial Assessment, HIV/AIDS Assessment, Diabetes Assessment, etc.) The ability to identify medications (prescription and over-the-counter) and allergies, including drug, food, or environmental. Identifiesmembers for high risk complications and coordinates care in conjunction with the member and the health care team. Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits. Obtains a thorough and accurate member history to develop an individual care plan. Establishes short and long term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs such as Project AIDS Care or Long Term Care. The RN has overall responsibility to develop the care plan for services for the member and ensures the member's access to those services. May assist with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible. Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on the development of care management treatment plans. May also assist in problem solving with providers, claims or service issues. Directs the work of any LPN/LVN, LSW, LCSW, LMSW, and other licensed professionals other than an RN, in coordinating services for the member by, for example, assigning appropriate tasks to the non-RN clinicians, verifying and interpreting member information obtained by these individuals, conducting additional assessments, as necessary, to develop, monitor, evaluate, and revise the member's care plan to meet the member's needs. Works with the SHP Claims Department in assisting with questions in the claims reconciliation process .
R equires an RN; 3-4 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Masters in Health/Nursing preferred. May require state-specified certification based on state law and/or contract. Case Management experience - 1 year minimum preferred in Ryan White, PAC Waiver or other program working directly with persons living with HIV/AIDS. Managed Care experience - 1 year minimum preferred. Experience with Medicaid and Medicare preferred. Experience with behavioral health and substance abuse services - preferred. Proficiency in computerized systems. Uncompromising commitment to the Plan development and care delivery. Full knowledge and understanding of the case management/disease management process especially as it relates to HIV Disease. Understanding of Federal and State program requirements. Professional credibility. Bilingual - preferred. Travel required.
/ Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at //antheminc.com/careers/ / . EOE. M/F/Disability/Veteran. /
Title: RN Case Manager - Tampa/Miami, FL - #123027
Other Locations: FL-Miami
Requisition ID: 123027
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