Job Description

• The Care Coordinator for transplants/ESRD (End stage renal disease) RN Coordinator, acts as the lead facilitator of the multidisciplinary case management team and is a Registered Nurse (RN). The focus of the role is managing and directing high-risk, high-cost members to appropriate resources, services and programs. This position specifically works with transplant/ESRD members. In order to accomplish they evaluate and plan for comprehensive coordination of care and health services to manage members across the continuum. They partner and collaborate with the integrated team and partners in order to provide seamless exchange of information between providers, members, and caregivers with the ultimate outcome to improve quality, reduce costs and enhance member experience. In addition to care coordination, responsibilities include, but are not limited to Utilization Management functions that involve coordinating assigned utilization benefits, quoting benefits, and ensuring procedures meet all medical criteria.

Essential Functions

Coordinates and manages complex medical cases and health care needs across the continuum of care for both Medicare Advantage and Commercial members. Specific focus on members with transplant and End Stage Renal Disease (ESRD) diagnoses.

Conducts member assessments, identifies gaps and interventions, and coordinates ongoing care with physician and integrated team.

Develops initial and quarterly personalized care plan with member and the primary care provider (PCP).

Maintains continuity of longitudinal documentation appropriate for continuity of care.

Helps the member create / coordinate a support team in their local community to help them manage their long-term health status independently.

Tracks the top coordination tasks needed by most complex cases and when they are completed will be graduating the member to monitoring status and / or other programs.

Lead facilitator of the multidisciplinary care coordinator team managing and directing high-risk, high-cost members to appropriate resources, services and programs.

Care Coordinators will focus on 1% commercial and 5% Medicare targeted/prioritized complex cases, subject to further analysis.

Creates care plan summary and communicates / discusses with the PCP and member.

Assigned to embedded locations or geographic areas / service areas.

Know the Utilization Management (UM) and Care Coordination (CC) work flows.

Build working relationships with providers for transplant concerns.

Willing to learn the system for contracts and single case agreements for different insurance plans.

Quote benefits related to transplants to members based on their plan.

Perform On Call via a rotation schedule for the weekends to meet the regulatory guidelines for transplant members.

• EDUCATIONAL REQUIREMENTS
  College Diploma in Nursing
  CERTIFICATION & LICENSURE REQUIREMENTS
  Registered Professional Nurse (RN) License Illinois upon application.

  Compact license not eligible for this position must be IL.
  EXPERIENCE REQUIREMENTS
  Requires two (2) years nursing experience in clinical, healthcare, or social service settings. Case management experience and Utilization Management experience preferred.
  ADDITIONAL REQUIREMENTS
  

  • On Call- On Call is required over the weekends on a rotation schedule to ensure regulatory guidelines are met for members with Transplant health care needs.

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