TX STAR+PLUS Service Coordinator 1-RN Case ManagerPrimary Location: McAllen, TX
Additional Locations: TX-McAllen Apply
68144Fundamental Components: Assessment of Members: Through the use of clinical tools and information/data review, conducts comprehensive face to face assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan/s and available internal and external programs/services. - Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues..- Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services. Actively engage with providers and member during key transitions of care. Enhancement of Medical Appropriateness and Quality of Care: - Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits - Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes - Identifies and escalates quality of care issues through established channels -Ability to speak to medical and behavioral health professionals to influence appropriate member care. - Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health -Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. -Helps member actively and knowledgeably participate with their provider in healthcare decision-making -Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs and co-morbid conditions. Reviews prior claims to address potential impact on current case management and eligibility. Assessment includes the member's level of work capacity and related restrictions/limitations. Monitoring, Evaluation and Documentation of Care: -In collaboration with the member and their care team develops and monitors established person-centered plans of care to meet the member’s goals -Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures. Background Experience:
- Case Management in an integrated model preferred
- Bilingual preferred (Spanish)
- 3+ years clinical practice experience RN with current unrestricted state licensure required
- RUG certified RN; or ability to complete RUG certification within 60 days of start date is required
- 2+ years health plan experience is preferred
- Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel. Strong keyboard and mouse skills required.
- Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
- Effective communication skills, verbal and written.
- HIDALGO SERVICE AREA: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Start, Webb, Willacy and Zapata counties.
- Use of personal vehicle when traveling in the field, must have active and valid TX driver's license, reliable transportation and vehicle insurance.
- Working environment with productivity and quality expectations
- Ability to multitask, prioritize, and effectively adapt to a fast changing environment
- Effective communication skills, both verbal and written
Jobs for you
Recently Viewed Jobs
You do not have any recently viewed jobs
Your Saved Jobs
You do not have any saved jobs
Sign up for Job Alerts
Join our Talent Community
At Aetna, a CVS Health Company, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna, a CVS Health Company.Sign Up
Join Our Talent Community
Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna, a CVS Health Company.