Senior Rn Utilization Review Nurse Jobs in Reno, NV

Registered Nurse Complex Case Manager

Position Description

The RN Complex Case Manager (CCM) is a highly-skilled, licensed nurse responsible for maximizing the efficiency and effectiveness of health care interventions necessary for a patient to attain the optimal results from his or her plan of care. The (CCM) identifies patient needs at the individual and population levels to effectively plan, manage and coordinate patient care in partnership with patients/families/caregivers. Emphasis is placed on supporting patients at highest risk.

Minimum Qualifications

• Graduate of an accredited nursing school required. Bachelor’s degree in nursing preferred
• Licensure as a registered nurse in the state of Nevada required
• Current CPR or BLS certification required
• Minimum three years of experience in a clinical practice, ER, ICU with good clinical skills
• Familiarity with Electronic Health Record systems required
• Minimum two years experience in complex case management required

Responsibilities / Functional Job Description

The RN Complex Case Manager is responsible for the complex clinical management of designated high-risk patients in the ambulatory setting. The CCM will be involved in the coordination of services, assessment, monitoring and evaluation of the comprehensive health care needs of high-risk patients ensuring delivery of quality, cost effective health care in a patient centered environment.

The CCM works to avoid duplication and misuse of medical services, control costs by reducing inefficient services, and improve the effectiveness of care delivery system leading to the enhancement of the patient care experience and improving patient outcomes. The Complex Case Manager is dedicated to patient-centered care that values personal self-determination, behavior change and engaging in creative, compassionate and ethical problem-solving. The Complex Case Manager works in coordination with an interdisciplinary team to achieve the organization mission as well as department specific goals and objectives.

ESSENTIAL DUTIES AND REPONSIBILITIES

Responsible for the case management of the member population who are eligible for and require continuous, chronic and/or high intensive level of case management.

• Identifies the targeted high risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
• Responsible for working collaboratively with all healthcare team members.
• Support and participate in the interdisciplinary team approach, working collaboratively to develop and implement treatment plans that support the patient-centered plan of care to ensure excellent member satisfaction, effective resource utilization, improved quality of care and cost-effective outcomes.
• Ability to monitor and assure the patient's timely access to the appropriate level of care; the right health care providers; and the correct setting and services to meet the patient's needs; promote coordination and continuity in patient health care.
• Assesses for, develops, monitors and acts on care plan interventions to meet patient centered, clinical and utilization goals while considering of the full continuum of care available to the patient, the interrelationships of the care components, and their effective integration.
• Acts as a liaison and resource in collaboration with physicians and their office staff, hospitalists, care facilities, ancillary providers, health plan case managers and internal departments.
• Interprets data and trends using appropriate analytical skills to include utilizing existing reports and systems to identify and monitor utilization patterns, risk stratification, and gaps in care.
• Provides timely responses to inquiries from health plans and providers concerning members in complex case management. Generates case management logs and submits them in a timely manner.
• Responsible for developing a comprehensive individualized plan of care and targeted interventions.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Provides follow-up with patient/family when patient transitions from one setting to another.
• Actively participates in clinical outcome measurement and identifies strategies and opportunities to promote population health.
• Develops effective working relationships with providers, health center leadership and support staff to ensure the needs of the care team are being successfully met.
• Analyzes and provides recommendations for ways to improve customer service, improve patient flow, clinical outcomes, increase productivity, and improve utilization of resources
• Participates in quality improvement activities
• Adheres to all HIPPA,OSHA, state, other regulatory agencies and NVHC lab manual policy and procedures requirements
• Other duties and special projects as assigned

Desired Knowledge, Skills & Abilities

• Knowledge of the essential functions, practices and procedures of a medical clinic and office
• Knowledge of in office procedures
• Ability to interact effectively and positively with other staff members
• Detail oriented and ability to handle multiple and shifting priorities
• Excellent ability to problem solve, deescalate/resolve conflict and perform service recovery.
• Ability to effectively utilize AIDET tool set
• Demonstrated ability to produce high quality work in a consistent manner
• Demonstrated ability to manage timelines and projects successfully
• Computer literate, with ability to prepare complex reports and analysis

NVHC’s Equal Employment Opportunity Statement:

Nevada Health Centers will provide equal opportunity employment to all employees and applicants for employment. No person shall be discriminated against in employment because of race, color, gender, age, national origin, ancestry, religion, physical or intellectual disability marital status, parental status, sexual orientation or any other category protected by law.

Americans with Disabilities Act (ADA) Statement

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand and walk for prolonged periods of time in an ambulatory patient care setting; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is regularly required to stand; walk; stoop, kneel, or crouch. The employee must regularly lift and/or move up to 20 pounds.