Catastrophic Case Management RN

The Commercial Catastrophic Case Management clinical advisor supports Humana members by identifying and utilizing appropriate healthcare resources most consistent with the member’s needs and by providing guidance along the healthcare continuum. The clinical advisor works with identified health plan members to assess their care needs, assist in coordinating interventions and services to meet those needs, and communicating with members, providers, and Humana associates to promote efficient use of the healthcare system. The clinical advisor utilizes knowledge of benefit plan design and care alternatives available within the community and nationally in order to recommend services that represent the delivery of appropriate health care services for Humana Plan members as ordered by the member’s care provider(s). This work requires the ability to work via cable or DSL modem from home as needed in a secure environment where confidentiality of member and company information can be maintained.
Core Competencies:
oCommunication: The clinical advisor identifies and understands the needs and perspectives of others. He/she understands the audience and tailors delivery accordingly; shares information appropriately. The clinical advisor presents information and/or recommendations verbally, graphically and/or in writing that is articulate and succinct.
oProblem Solving: The clinical advisor proactively identifies and evaluates problems. He/she identifies appropriate subject matter experts and other information resources to resolve problems. The clinical advisor is able to collect, analyze, and draw conclusions from information and is able to differentiate between symptoms and root cause--effectively handles resolution or hand-off of both components. Implementation/Execution: The clinical advisor effectively leverages available resources (financial, people, time) to accomplish objectives and maximize return on investment. He/she makes appropriate decisions in the face of ambiguity. Anticipates and resolves barriers and constraints.
oTechnology: The clinical advisor chooses and adeptly uses appropriate technology tools, methodologies and solutions. From the telephone to the computer, the clinical advisor is at home with electronic technology and uses it as a matter of course. The Internet is a familiar place where the clinical advisor is able to navigate and find resources, information, and tools to help guide members. The clinical advisor is able to learn via the internet and within a virtual environment.
oAssessment: The clinical advisor evaluates members with specific diagnoses, identified as having been historically associated with opportunities for improved discharge planning. Re-assessment occurs on a cycle consistent with the Clinical advisor's impression of the member’s needs and clinical status.
oPlanning: The Clinical advisor works with the member, guardian, provider, and other members of the health care delivery team to identify the member’s need and resources to meet those needs.
oCoordination: The clinical advisor facilitates the member’s transition through the continuum of care by assisting with or obtaining appropriate referrals or authorizations for services. The clinical advisor identifies participating providers and acts as an additional resource in coordinating the member’s transition to the most appropriate level of care.
oMonitoring: The clinical advisor attempts to contact anyone who receives case management services while in an inpatient setting, at least 1-2 business days post-discharge. During contact, the clinical advisor evaluates whether or not the discharge plan was implemented and if post-follow-up monitoring is scheduled or required.
oEvaluation: During post-discharge contact, the clinical advisor evaluates the adequacy of the discharge plan and member’s satisfaction with services provided. The clinical advisor will also evaluate for further Humana program options. Periodic contacts will be scheduled as warranted by the members need for ongoing coordination and support
REQUIREMENTS
Educational Requirements:
oRegistered Nurse
oCurrently holds a valid nursing license with out restrictions in their designated location
oBachelors Degree in Nursing, Management, or Health Related Field preferred but not required
oAt least 5 years of clinical experience in an acute clinical medical setting
oPrevious experience in catastrophic case management preferred
oCCM (certified case manager) certification or eligibility desired
oBilingualism an asset but not required