Imagine360 is currently seeking a Transplant Case Manager RN to join the team! The Transplant Case Manager, RN is responsible to providing case management for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical and professional experience. The Registered Nurse will practice within the scope of nursing practice while performing assessments, coordinating care, planning, monitoring, evaluating and determining outcomes.
Who we are: At Imagine360, we are fixing health insurance. To help businesses and their employees navigate through clutter and chaos and bring deep cost savings that protect everyone's well-being and budgets. It's way more than a health plan. It's a promise. For more than 12 years, we've helped hundreds of self-funded clients use reference-based pricing to maximize savings and control costs. Our approach is proven. Our solutions are ready to implement. The results are real.
Specialties: Plan Design, Direct Contracting, Claims Auditing, Designated Decision Making, Member Advocacy and Defense, Analytics, Self-Insurance, and Healthcare Cost Containment.
Position Location: 100% Remote
Responsibilities include but are not limited to:
- Identify, collect, process, and manage data to perform the Case Management process by utilization Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures
-
Completes clinical assessments per P&P to identify and deliver indicated medical service coordination.
-
Manage the transplant cases, cases that may lead toward organ transplant, and complex disease cases.
-
Utilize clinical knowledge, expertise, and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment.
-
Assess the need for and collaborate with community resources for members in case management.
-
Uses assigned software accurately to document to complete and document all steps of review of medical necessity and case management process, including time slips.
-
Facilitate the Patient Satisfaction Surveys
-
Assess for cost savings and document the cost saving in assigned software
-
Appropriately refer complex cases to Supervisor, Case Management, or designee
-
Performs essential activities of case management while maintaining members' confidentiality, safety, advocacy, adherence to ethical, legal and accreditation and regulatory standards.
-
Performs assessments of each member to identify CM needs.
-
Consistently exercises discretion and judgment to analyze, interpret, make deductions, and then decide what actions are necessary based on the varying facts and circumstances of each individual case.
-
Determines measurable goals utilizing motivational interviewing and behavior change model and coaches' clients while monitoring self-care practices.
-
Utilizes industry standard tools to guide individuals with chronic/ongoing health conditions through coaching, assessments, listening, and other techniques as appropriate.
-
Executes activities or interventions to achieve the goals in the plan.
-
Organizes, integrates, and modifies the resources needed to reach the goals in the plan.
-
Monitors all information from all relevant sources in the plan and its activities and services to determine the plan's effectiveness.
-
At repeated intervals, evaluates to determine ultimate effectiveness of plan and modifies plan appropriately to meet the goals.
-
Research medical procedures, treatments, and coding when necessary.
-
Measures the outcomes of interventions.
-
Adheres to practicing the care management core components throughout the continuum of care:
-
Case Management Concepts
-
Case Management Principles and Strategies
-
Psychosocial and Support Systems
-
Healthcare Management and Delivery
-
Healthcare Reimbursement
-
Vocational Concepts and Strategies.
-
Customer Service
-
Acts as a role model in demonstrating the core values in customer service delivery.
-
Provides timely and thorough follow up with, internal and external customers.
-
Appropriately escalates difficult issues up the chain of command.
-
Quality Assurance
-
Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
-
Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
-
Performs self-quality monitoring to develop and execute plans to meet established goals.
-
Provides ongoing feedback to help optimize quality performance.
-
Collaborates with others and cross-departmentally to improve or streamline procedures.
-
Develops new or improves current internal processes to improve quality.
-
Attend and participate in team meetings, trainings, and other job specific events as required.
-
Communicates (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives and stop loss as needed.
-
Communicates professionally and effectively.
-
Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and Procedures.
-
Participate in the Quality Management Program via collecting and adhering to performance metrics per Case Management Policy
-
Complete HIPAA Training Annually.
-
Perform all tasks in accordance with HIPAA/PHI guidelines.
-
Appropriately escalate difficult issues.
-
Complete duties in accordance with scope of licensure and certifications held or requested.
-
Perform other duties and projects, as assigned.
Areas of Responsibility Scope of Practice:
-
In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making and patient education. The scope of practice includes, but is not limited to:
-
Evaluating clinical data
-
Assessment and evaluation of the acquired clinical date to assess for appropriateness of treatment based on Imagine360 clinical guidelines,
-
Coordination of treatment plans, interventions, and outcome measurement
-
Rationale for the effects of medication and treatments
-
Provide patient education and educational resources.
-
Accurately report:
-
Administration of medication and treatments
-
Client response
-
Contact with other health care team members.
-
Respect the client's right to privacy by protecting confidential information.
-
Promote and participate in education and counseling to a participant based on health needs.
-
Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner.
-
The Team Lead, Case Management will have knowledge and practice the core components of Case Management that include:
-
Case Management Concepts
-
Principles of Practice
-
HealthCare Management & Delivery
-
Healthcare Reimbursement
-
Psychosocial Aspects of Care
-
Rehabilitation
-
Professional Development & Advancement
-
Quality and Outcomes Evaluation and Measurement
-
Ethical, Legal and Practice Standards
Required Experience / Education:
- Nursing degree from an accredited college, university, or nursing school
-
2+ years in Utilization Review or transferrable nursing experience and skills
-
2+ years in Case Management or transferrable nursing experience and skills
What can Imagine360 offer you?
- Multiple Health Plan Options, including a 100% Employer Paid Benefit Options
-
100% Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance
-
Parental Leave Policy
- 20 days PTO to start / 10 Paid Holidays
- Tuition reimbursement
- 401k Company contribution
- Professional development initiatives / continuous learning opportunities
- Opportunities to participate in and support the company's diversity and inclusion initiatives
Want to see our latest job opportunities? Follow us on LinkedIn
Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.
Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**