Posted: Dec 22, 2017
Intensive Case Management - ICM services are available to those with special needs. The ICM program is designed to assist members in finding resources in the community and assist with complex medical situations. ICM services are a coordinated team effort and involve both clinical and non-clinical personnel. The ICM team will assist in coordinating care with the primary care physician and other care providers, such as hospitals, home health agencies, North West Senior and Disability Services (NWSDS) and Department of Human Services (DHS) child protective services.
Position Summary: ICM RN provides intensive case management services to members identified:
• as aged, blind, or disabled,
• as having complex medical needs,
• as having high health care needs,
• as having multiple chronic conditions,
• as having behavioral health issues, and/or
• as having severe and persistent mental illness receiving home and community based services under the state’s 1915(1) state plan amendment for the ICM program.
While the following detail of job functions cannot include all possible activities, it is intend that the ICM RN will work within the nationally recognized framework of essential activities related to all aspects of healthcare delivery systems in general, and individual patient care in particular. These activities include, but may not be limited to:
ESSENTIAL JOB FUNCTIONS:
ICM services may be requested by the member, the member’s representative, the member’s physician, and/or other medical personnel serving the member or the member’s agency case manager. The ICM team will respond to requests for IMC services with an initial response by the next working day following the request.
The ICM RN will:
• Triage potentially high need members requesting ICM services and coordinate services around member’s need.
• Review and evaluate proposed and existing services using medical necessity criteria, program policies/guidelines and other pertinent rules & regulations such as Oregon Administrative Rules, CMS rules, payment & utilization policies determined by other third party payers, and internal policies and procedures.
• Works with internal/external entities and support systems to facilitate and coordinate ongoing services including discharge planning, referrals or preauthorizations.
• Interview and assess members and/or their caregivers both on the phone and in person.
• Assist members and/or their caregivers in obtaining access to medical and behavioral health services, education, legal counseling, and community and assistance programs.
• Assist members and/or their caregivers in understanding their health benefits, rights and responsibilities.
• Authorize the least costly alternative that is medically appropriate within each plan's benefit structure.
• Assist with communication of pertinent medical information to and from the Primary Care Physician (PCP) and the involved specialist(s), if applicable, to address the need for ongoing care.
• For those members with ongoing needs, re-assess and modify the integrated plan of care to assist the member to obtain maximum wellness given their health and human services needs.
• Document all steps taken in the case management process including the evaluation, the plan and its implementation, the reassessment, any required modifications to the plan, the outcomes of the plan, and any further other duties undertaken.
• Interact with Provider Relations personnel to maintain and foster good working relationships with physicians and other providers. Providers must be periodically informed of the availability of ICM services.
• Assist in training for patient centered primary care homes and other PCP staff on ICM services and other support services available for members.
• Maintain case management knowledge and training through internal or external resources.
• Meet with member face to face as needed.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
• Experience with case management, medical utilization, and quality improvement procedures.
• Ability to work independently and serve as a team member.
• Ability to lead and coordinate both clinical and non clinical personnel.
• An educative approach to answering questions and informing people of health plan policies, procedures, or decisions.
• A firm confident responsiveness that maintains the organizations’ integrity.
• The ability to handle sensitive situations and stress effectively and project a positive attitude.
• Ability to communicate effectively, both orally and in writing, with medical professionals and non-professionals, especially with plan members.
• Maintain professional ethics and confidentiality at all times.
• Must exhibit excellent organizational skills.
• Must be computer literate with Microsoft Office Suite and networked PCs.
• Must document all steps taken in the case management process, including the evaluation, the plan and its implementation, the reassessment and any required modifications to the plan, the outcomes of the plan, and all other duties undertaken.
• Support and practice the Code of Conduct.
• Must be willing to deal with members who may exhibit inappropriate, disruptive, or threatening behaviors in a practitioner’s office, clinic, or other setting.
• Ability to effectively interact and respect co-workers, members who have a diverse ethnic or cultural backgrounds, religious views, political affiliations, lifestyles, and sexual orientation.
• Certification as a Certified Managed Care Nurse (CMCN) preferred.