Nurse Case Manager – Work From Home Nursing Jobs

Job Type: Nurse Case Manager from home
Location: California work from home
Company: Acentra Health

RN: The Nurse Case Manager

• Uses clinical knowledge, contract requirements, critical thinking, and decision-making abilities to evaluate medical records against relevant criteria in order to assess medical appropriateness while upholding QA standards and production targets.
• Makes certain that routine procedures are carried out in compliance with URAC, NCQA, and other legal requirements.

Responsibilities:

• Makes contact with patients in need of health coaching programs and conducts initial interviews with them.
• gives the required instruction to cut down on or stop actions deemed high-risk.
• Determines the necessary objectives that every patient needs to meet and provides advice on practical ways to reach the objectives.
• informs participants about health-related challenges and concerns as well as possible solutions.
• makes use of the proper motivational interviewing skills required to coach and help the patient finish an action plan or goal for self-management.
• keeps up-to-date knowledge about complex drugs and related therapies for conditions like diabetes, asthma, COPD, HTN, CHF, and other conditioncontinuously evaluates the review procedure to identify areas for development and/or modification.
• Utilizing the Chronic Care Model, conducts clinic one-on-one visits with participants in the Disease Management Chronic Care Program to determine the patient’s needs for DME, home health, value-added services, and any other resources that may be required.
• cultivates a good and professional rapport and serves as a point of contact for both internal and external clients to guarantee productive working relationships and team development, which will aid in the review process.
• consistently upholds the privacy of medical records by adhering to HIPAA regulations, using computer passwords appropriately, and maintaining safe files.
• employs appropriate phone manners and makes prudent use of other written and verbal communications, adhering to Acentra Health policies, procedures, and directives.
• actively trains to fill roles under different contracts within the Acentra Health network in order to offer a workforce that is adaptable to suit the needs of clients and consumers.
• The list of responsibilities is not meant to be exhaustive and could occasionally be updated to incorporate other tasks that management may see important.

Requirements:

Requirements for Education and Experience:

• Active, unrestricted clinical licensure as an RN from Oregon State, as required by the contract.
• Completion of a Bachelor of Science in Nursing program with accreditation.
• A minimum of one year of clinical experience in a medical-surgical or acute setting.
• Experience managing diseases or cases for at least a year.
• abstracting skills for medical records.
• familiarity with medical language, record organization, and illness progression.
• Outstanding decision-making, problem-solving, and communication abilities.
• the capacity to organize and prioritize work well.
• Capacity to operate in a group setting.
• adaptability and excellent planning abilities.
• Proficiency in Microsoft Office and online/web navigation is required.

Preferred Education and Work History:

• Certification in Case Management/CCM.
• Awareness of the most recent URAC (Utilization Review Accreditation Commission) and National Committee for Quality Assurance (NCQA) standards.
• Prior authorization, Utilization Review (UR), and/or relevant experience.
• familiarity with InterQual standards.
• knowledge of ancillary services, such as hospice, SNF, HHC, etc.
• expertise in handling difficult or disastrous medical situations.
• experience guiding others to adopt healthier habits.
• pursuing or earning an advanced degree or CCM, CCP, or CDE certification.