Nurse Care Manager Resume Samples

Description :

1. Identifying the potential clients suitable for case management intervention.
2. Initiating contact with member/family, physician, and health care providers/suppliers to discuss the ATP/discharge possibilities and solicit information.
3. Conducting a thorough and objective evaluation of the clients current status including physical as well as psychological.
4. Preventing the prolonged hospitalizations and allowing the discharge from hospitals and other settings when a client's needs can be provided for in a more cost-effective, less intensive setting.
5. Coordinating appropriate utilization of contract benefits for providers, physicians, and members.
6. Coordinating and implementing the delivery of approved services for the alternative treatment plan/discharge plan.
7. Taking the responsibility for extensions, revisions, or termination of previously established plans.
8. Providing case management reports on a monthly basis to the manager and as requested.

Experience

7-10 Years

Level

Senior

Education

Associates

Description :

1. Providing the case management service to address the psychosocial concerns, community resources, and Medicaid benefits for the patient to promote improved quality of care and cost-effective outcomes.
2. Collaborating with the primary care provider, department of social services, mental health, and other community agencies to ensure continuity of care.
3. Taking an active role in assisting the patient to transition from the hospital to their home by completing medication reconciliations and referrals to the specialist.
4. Assessing the patient's needs effectively to make appropriate referrals as the level of care increases and changes.
5. Making referrals to other providers/agencies when requested.
6. Coordinating the proper referrals, procedures, and medications.
7. Identifying high-risk clients for targeted disease management to reduce inpatient admissions by identifying risk factors for readmission, reduce medication discrepancies by completing medication reconciliation with the collaboration of a pharmacist and promoting healthcare management of chronic conditions.
8. Providing an initial and ongoing assessment of patients to identify needs/issues, care goals and appropriate resources necessary for case management.
9. Responsible for assessing, planning, implementing, coordinating, monitoring, and evaluating the healthcare needs of the Medicaid eligible client.

Experience

7-10 Years

Level

Senior

Education

MS

Description :

1. Engaging members and guiding them to develop lifelong wellbeing and health.
2. Visiting our members in their home and using a compliment of instruments that will help to identify gaps in care and implement strategies.
3. Guiding and facilitating the interaction with resources appropriate for their care and well-being. 
4. Evaluating the member needs and implementing the appropriate interventions with Humana at home members participants in their place of residence (home, assisted living or long-term care facility).
5. Completing physical, psychological, emotional and environmental reviews of the assigned members in order to provide appropriate, timely interventions to optimize care.
6. Developing the plan of action with your assigned member based on identified needs and recommend and/or coordinating interventions that may include information, education, resources, and referrals.
7. Working collaboratively with all staff to ensure appropriate intervention implementation with advocacy organizations and healthcare facilities.

Experience

10+ Years

Level

Consultant

Education

Associates

Description :

1. Initiated and coordinated continuity of care in the primary care setting, including referrals, prior authorizations.
2. Maintenance of emergency medication, communication with health insurance companies, specialists, DME.
3. Performed bilingual health assessments and follow up, screenings, immunizations, and health education for chronic health conditions.
4. Developed and implemented bilingual, culturally competent diabetes and asthma education curriculum.
5. Triaged walk-in and call-in adult and pediatric patients to develop individualized care plans.
6. Spearheaded interdisciplinary team initiatives; documented and executed the plan of care as appropriate.
7. Organized and managed annual mammogram van event for Medicaid and uninsured patients.
8. Facilitated the communication with Fox Chase Cancer Center, recruiting patients, and executing logistics day of the event.
9. Precepted and supported 3 nursing students and intern on clinical rotation.
10. Functioned as Interim RN Clinical Support Manager, including maintenance and coordination of vaccines.
11. Supervision of 5 support staff, management of medical supplies and in-house medication.

Experience

2-5 Years

Level

Junior

Education

BS

Description :

1. Solely responsible for implementing and achieving recognition of NCQA certification, with extensive knowledge of NCQA standards and supporting factors.
2. Developed an organized system, control activities, methods and procedures to achieve NCQA accreditation objectives.
3. Included analyzing current clinical processes, ensuring supporting documentation is available, and identifying gaps by conducting a needs analysis, resulting in developing a plan of action towards the goal of NCQA certification.
4. Formulated and established policies and operating procedures to ensure compliance of internal and external guidelines.
5. Directed the leadership meetings and large medical home group clinical meetings, reviewing clinical operations, quality.
6. Researched and incorporated high-risk patient population quality improvement projects initiating high-quality care.
7. Initiated and achieved 90% quality improvement project of care plan development exceeding the 75% NCQA goal.
8. Achieved 48% quality improvement project of reducing ED utilization of high-risk population exceeding the 30% goal.
9. Initiated the preventive screening of patients due for colorectal screenings meeting the goal of 71%.
10. Developed process to achieve 79.7% quality improvement project on depression screening during office visits.
11. Performed clinical documentation internal reviews to maintain compliance with the regulatory bodies and standards.

Experience

5-7 Years

Level

Executive

Education

BS

Description :

1. Providing care management to coordinate, integrate and monitor medical services, follow-ups and recommendations in all nursing and medical care.
2. Monitoring for completion of recommended treatments/referrals, reviews charts, perform nursing assessments of clients during weekly home visits or as needed.
3. Developing a plan of care, and plan of nursing services, and provide in-service training as well as instruction and supervision to the non-licensed staff for all delegated nursing tasks.
4. As a member of the medical-clinical team: attend the monthly clinical meeting, client medical review that is part of residential planning, the Individualized Service Plan (ISP) and the Plan of Protective Oversight (POP) as per agency policies and procedures.
5. Completing the weekly visits on site to monitor medication administration surveillance, give guidance, and direction to staff and observe the clients' health care status.
6. Teach NYS training curriculum called: AMAP (Approved Medication Administration Personnel).
7. Completing the performance/competence of staff periodically, in conjunction with AMAP certification process, as part of the residential staffs' performance appraisal.
8. Providing nursing coverage at all times via phone, covering the on-call nurse after hours and weekends for medical consultation and nursing triage services.

Experience

7-10 Years

Level

Senior

Education

BS

Description :

1. Providing after-hours support to hospitalist in the coordination of care from out of the area to core facilities (Non- Contracted facilities to Contracted Facilities).
2. Implementing the current policies and procedures set by the care management department.
3. Reviewing the patient referrals within the specified care management policy timeframe (type and timeline policy).
4. Coordinating the treatment plans and discharge expectations and discusses DPA and DNR status with attending physician when applicable.
5. Prioritizing patient care needs and telephonically discussing the treatment plans with patients and appropriate representatives of the HCP patient.
6. Consulting with the physician and other team members to ensure that care plan is successfully implemented.
7. Coordinating the provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc. , in order to maintain continuity of care.

Experience

10+ Years

Level

Consultant

Education

College

Description :

1. Developing Personal Care Service Plan (PCSP) with UAS and clinical assessment protocol and ensuring the compliance with completing, analyzing and verifying by end of each month.
2. Collaborating and coordinating with LHCSA to ensure clinical assessment is conducted as authorized for each member.
3. Responsible for oversight, intervention, and management of assigned members, care management, service authorization and ensuring a smooth transition to care.
4. Facilitating the discharge planning for hospitalized members.
5. Responsible for identifying and presenting members in complex care management meetings and ensuring authorization for all services.
6. Responsible for referral and coordination of necessary health related services whether services are covered under MLTC.
7. Performing home visits, evaluating the member's health status and follow up on health prevention measures.
8. Completing the grievance and notice of action for the member and participates in the tasking review team meetings.
9. Coordinated a case load of 190 members being seen by the visiting nurses. Provided supervision and instructions to the visiting nurse.

Experience

10+ Years

Level

Consultant

Education

BSN

Description :

1. Establishing a plan of care with patients, providers, and payers that identifies and continuously reassessing cost-efficient, appropriate levels of care.
2. Enhancing communication and collaborative relationships with multidisciplinary healthcare team members.
3. Emphasizing continuity of care, thus reducing or eliminating fragmentation, duplication, and gaps in the treatment plan.
4. Acting as a patient advocate protecting privacy and confidentiality issues.
5. Providing patient education, monitoring of health needs, and coordinating of community resources.
6. Preventing adverse patient occurrences when possible and intervening quickly if prevention is not possible, thereby minimizing poor outcomes.
7. Facilitating patient empowerment and quality of life by promoting educated, the independent patient choice on all aspects of care.
8. Maintaining a comprehensive working knowledge of community resources, payer requirements, and network services for the target population.
9. Identifying opportunities for health promotion and illness prevention.

Experience

2-5 Years

Level

Junior

Education

Associates

Description :

1. Providing care to members with EDCD waiver (Commonwealth Coordinated Care Program).
2. Conducting a comprehensive assessment of the members' health and psychosocial needs, including health literacy status and deficits, and develops a case management plan collaboratively with the member and family or caregiver.
3. Facilitating the communication and coordination between members of the healthcare team, involving the member in the decision-making process.
4. Educating the member, the family or caregiver on disease process and management, medication.
5. Encouraging the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case-by-case basis.
6. Participating in the ongoing quality improvement process, and participating in case management rounds/meetings, in addition to ICT meetings.
7. Interviewing the members telephonically, in the physicians office, home visits or in other facilities to provide initial and ongoing case management services.
8. Conducting regular discussions and updates with the members' primary care physicians, other providers and members of the multidisciplinary health service team.
9. Communicating the potential denials for continued stay with the coordinator and medical director(s) for determination.

Experience

2-5 Years

Level

Junior

Education

Diploma