GENERAL SUMMARY
RN Needed for Special Needs Program
Functions as the central coordinator of care across all settings and providers for members identified as having chronic disease processes. Implements, monitors, and improves a disease management program. Manages the program for a particular disease ensuring that the population is tracked and evaluated, appropriate activities are implemented, practitioners and members receive communication, and that systems are in place for case management referrals.
ESSENTIAL RESPONSIBILITIES
- Implements a disease management program, including utilizing the clinical support tools to track and monitor the care provided to the disease population.
- Develops communications to physicians, other professionals, and members about the program, including outreach activities if appropriate.
- Develops program activities, such as educational interventions, and incorporates community resources, when appropriate. Researches disease management resources from educational and specialty organizations.
- Ensures that the disease management program is integrated and coordinated with other activities.
- Analyzes the data and identifies opportunities for improvement.
- Develops appropriate documentation and evaluation to determine the effectiveness of the program and meet accreditation standards for disease management programs, if relevant.
- Works with practitioners and other professionals to evaluate the clinical appropriateness of the disease management program and revise as needed with changes in clinical care and guidelines.
- Refers individuals for case management screening as appropriate.
- Ensures that the disease management population is receiving the appropriate tracking, monitoring, and outreach to assist that population to receive the care indicated by the disease management program.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- For employees providing disease management for members in the Special Needs Program Model of Care, this role is also responsible for implementing and coordinating all case management activities for the special needs population, including educating members on available services and benefits, triaging member’s care needs, conducting and analyzing health risk assessments, initialzing and implementing the members’ individualized care plan, ongoing review and updating of the members’ individualized care plan, use of community resources and alternative levels of care, coordinating care for beneficiaries across all care settings including provider services, assisting members with scheduling appointments, and follow up services.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered Nurse with current state license.
- Bachelor’s degree or equivalent experience preferred.
- Previous experience (usually 2+ years) in utilization management.
- Significant experience (usually 3+ years) clinical experience.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Miami, FL, US
Organization: 32000 - Florida Health Plan Admin. LLC
Schedule: Full-time
Job Posting: 2013-01-23 00:00:00.0
Job ID: 1310271