The LTSS Service Coordinator - RN Lead Clinician (US) is responsible for leading a team and assisting management with day to day activities, such as workforce management and monitoring and prioritizing workflow.
How you will make an impact:
Performs quality audits to ensure care plans designed optimize member's physical, behavioral, and social needs.
Assists in the development and maintenance of policies and procedures, training materials and job resources.
Leads projects and participates in workgroups with cross functional teams and serves as a representative on business unit/enterprise initiatives.
Performs process evaluations and tests and monitors systems/process enhancements.
Serves as first line contact for conflict resolution.
Participates in the Internal Appeal Process.
Responsible for overall management of member's case within the scope of licensure; provides supervision and 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.
Identifies members 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.
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.
Assists in problem solving with providers, claims or service issues. Serves as the first line contact for conflict resolution.
Directs and/or supervises 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, and reviewing and providing input on the non-RN clinicians' performance on a regular basis.
Serves as a mentor or preceptor for new staff, assists in formal training and may be involved in process improvement initiatives.
May also serve as lead to non-licensed LTSS Service Coordinators as applicable by state law and contract.
Minimum Requirements:
Requires an RN and minimum of 5 years clinical care experience and minimum of 5 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. BA/BS in health related field preferred.
May require state-specified certification based on state law and/or contract.
Preferred Skills, Knowledge, and Experience:
Certification as a Managed Care Nurse (CMCN) preferred.
MA/MS in Health/Nursing preferred.
Travels to worksite and other locations as necessary.
