Sr. Disease Manager - RN or Registered Nurse

Summary of Position: This position is responsible for the planning, development, implementation, and timely oversight of assessments, development of care plans, interventions, and educational materials for members with chronic conditions.  The incumbent is responsible for managing disease management processes as defined by NCQA, which includes improving coordination, continuity, accessibility, and appropriate utilization of health care services and community resources for members with chronic conditions.

 

Responsibilities:

Essential Functions:

?  Obtains verbal consent of the member for participation in the disease management program for all plans.

?  Identifies problems, sets goals, determines interventions, and the members health status based on assessment.

?  Conducts telephone interviews of members to identify risk factors and the need for disease management.

?  Initiates, develops, plans and implements care plans designed to promote the delivery of quality care and services to comply with regulatory requirements.

?  Communicates with primary care and/or treating physician to request specific health information and/or to provide an update of an individual?s health care status.

?  Transfers members needing more intensive management to case management, as indicated.

?  Performs follow-up on established care plan events and makes contact with the member in the disease management program, as appropriate.

?  Understands the benefits and restrictions of each plans specific requirements as related to disease management.

?  Documents in disease management software system member-specific assessments, education and outreach efforts consistent with regulatory and corporate requirements.

?  Prepares reports and case summaries as needed.

?  Completes special assignments and projects instrumental to the function of the department.  Works in conjunction with operational functions regarding clerical staff.

?  Utilizes clinical judgment to discharge members from disease management according to appropriate policies and procedures.

?  Educates members' medical providers regarding the members' progress in the program.

?  Coordinates, communicates, and refers members to community support and/or social service systems, as required.

?  Understands the identification process of high risk, high cost, impactable members and utilizes this predictive modeling tool to assist in the selection of potential disease managed members.

 Secondary Functions

?  Assists with special projects to meet change and departmental goals.

?  Following HIPAA guidelines, the Disease Manager maintains confidentiality of patient information and adheres to appropriate release of medical information procedures.

?  Demonstrates an understanding of the functions of other departments, communicates with other departments appropriately, and maintains a