The Complex Case Management Program is consistent with the case management industry guidelines: assessment, care planning, communication and coordination, education, empowering and advocacy. The goal of this program is to improve clinical outcomes and optimize service utilization and cost.
- The assigned Registered Nurse (RN) will operate within the company’s Clinical Care Delivery department providing onsite and telephonic care management services to Medicare Advantage individuals identified as “high risk members”
- Serve as the primary point-of-contact for a selected group of Medicare Advantage members and their families
- Will travel between the office, member's homes and acute and subacute facilities
- Will participate in twice weekly meetings with Medical Director to review member’s progress, update the plan of care as needed
- Active, unrestricted RN or LVN (BSN preferred) license in Texas
Willingness to obtain additional state licenses as needed for Oscar's growth (with Oscar's support)
- Utilization knowledge on Part A, Part B and part D Medicare.
- Medicare Advantage experience
- Two years case management at a managed care plan or provider organization and
- Knowledge of the evidence based guidelines for the main chronic conditions-HTN, CAD, Heart Failure, Diabetes, CKD and COPD.
- Ability to understand CMS guidelines.
- Understanding of the basic principles for OSHA, CLIA, HIPAA and AHCA.
- Excellent communication skills to effectively interact with members, families, and external healthcare providers
- Highly organized and self-motivated to effectively manage multiple members
Duties and responsibilities:
- Works in collaboration and continuous partnership with chronically ill or "high-risk" patients and their family/caregiver(s) in a team approach to:
- Reduce emergency room utilization and hospital readmissions
- Promote timely access to appropriate care
- Increase utilization of preventative care
- Initiates onsite hospital visits/rounds as needed to assess patient progress and meet with appropriate members of the patient care team
- Conduct initial in-home or facility visit to engage and educate the member (and their family/caregivers) to the Complex Case Management program
- Responsible for the coordination of post-discharge clinic appointments, medication reconciliation, PCP and specialist visits
- Manages transition of care ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member’s health care status changes
- Routinely conduct telephonic, in-home, and/or in-facility visits to monitor the member’s adherence to their established care plans
- Continuously coordinates, monitors, tracks and evaluates all care and services rendered to ensure that quality care is being delivered in the most appropriate setting
- Routinely discuss members’ care plans with the Medical Director to make adjustments as necessary
- Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)
- Increase patients’ ability for self-management and shared decision-making
- Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs
- Identifies and addresses psychosocial needs of the members and family and facilitates consultations with Social Worker
Knowledge, Skills, and Abilities:
- Knowledge of Electronic Medical Records.
- Ability to read, comprehend, and interpret medical coding and medical documents.
- Ability to be collaborative and effectively communicate with patient.
- Ability to have strong sense of urgency and use judgment to respond to emergencies.
- Ability to solve practical problems and deal with a variety of situations.
- Ability to write simple correspondence
- Ability to effectively present information in one-one and small group situations to clients and other employees of the organization.
- Bi-lingual in English and Spanish a plus.
At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we work to cultivate an environment where exceptional people can be their most authentic selves and find both belonging and support. We're on a mission to change healthcare -- an experience made whole by your unique background and perspectives.
Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ([email protected]) to make the need for an accommodation known.
Pay Transparency Policy: Oscar's Pay Transparency Policy ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.