CMSA - Atlanta Chapter

JOB SUMMARY: Responsible for managing members experiencing complex or catastrophic illness, high risk pregnancy, injury and/or specialty illnesses such as diabetes, HIV, transplant, behavioral health conditions, etc., to ensure cost effective and efficient utilization of health services. Conducts continuous skills assessment, planning, implementation, coordination, monitoring and evaluation.

PRIMARY RESPONSIBILITIES:

1. Obtains an accurate member history, conducts an assessment of biopsychosocial factors, and assesses clinical information to develop care plans including a member support system.
2. Establishes prioritized short and long term goals in collaboration with the member that meet the member’s needs and the referral source’s requirements.
3. Establishes working relationships with referral sources and community resources.
4. Identifies members with potential for high risk complications and coordinates the appropriate treatment in conjunction with the member and the health care team.
5. Collaborates with the member’s PCP and specialists in the development of the plan of care to ensure that members’ physical needs are addressed; communicates care objectives to appropriate individuals/departments/referral sources.
6. Provide case management and/or disease management services to members, as identified by a health plan’s referral process.
7. May be required to conduct field visits.
8. May be required to perform service authorization duties using prescribed criteria and responsibilities as assigned and required by the Plan
9. Acts as an advocate for an individual’s health care needs.
10. Reviews benefit systems and cost benefit analysis; evaluates the quality and necessity of applicable services; identifies members that would benefit from an alternative level of care; acquires data and evaluates necessary health services for cost containment; documents effectiveness of case management services
11. Participates in Quality Improvement processes and serves on internal and external committees as required.
12. Other duties as requested or assigned.

Education and Experience:

Education

Required:

• Nursing Diploma
• Associate’s Degree in related Health/Nursing field

Preferred

• Bachelor’s or Master’s Degree in related Health/Nursing field

Years and Type of Experience

Required:

• Minimum of three years clinically related experience

Preferred:

• Experience working on the community level and with community agencies
• Experience in managed care, case management and discharge planning

Certifications or Licensures

Required:

• Active licensed RN
• Must possess a valid driver’s license, motor vehicle insurance and access to a motor vehicle, or access to reliable public transportation within the service area

Preferred:

• Certified Case Manager

Language Skills

Required:

• English

Preferred:

• Bilingual

Functional Competencies

• Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad  Ability to review and draft correspondence in email system and word processing systems.
• Experience working with utilization management data systems

SCOPE INFORMATION

# Direct Reports: N/A

# Indirect Reports: N/A

Budgetary $ Responsibility: N/A

Physical Requirements:

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
• Ability to communicate both in person and/or by telephone.
• Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

RN TELEPHONIC CASE-MGR SUPERVISOR, WORKERS’ COMP - GEORGIA

USIS/AmeriSys, Atlanta, Georgia  (Dunwoody/Peachtree).  AmeriSys is the medical management division of USIS, Inc., a wholly-owned subsidiary of Brown & Brown, Inc., in business since 1939.  Adding to our wonderful team, we are seeking a Supervisor for Nurse Case-Managers.

 Job Summary:

Experienced Nurse Case-Manager with supervisory experience to assist Program Manager with the supervision of the triage, telephonic nurse case-management staff and utilization review staff for Georgia operations.  Responsible for maintenance of all State of Georgia MCO rules, and company standards.  Assist the Program Manager with QA audits and present minutes at monthly and quarterly QA/UR meetings.  Handle service issues with client claims staff.  Assist as TCM on Workers’ Compensation cases as necessary, for training, and during absences.

Qualifications/Competencies Required:

Registered Nurse – current license – with 3-5 years clinical experience (orthopedic, neurological, neuromuscular, ICCU, industrial or occupational)

CCM or equivalent certification is REQUIRED by State of GA

Case Management experience, preferably Workers’ Comp.

Supervisory experience with effective leadership skills, in support of company culture

Uphold the contractual requirements and standards set forth by URAC

Support the protocol, policies and procedures of the company.

Must work productively and independently to accomplish goals of the job

Possess excellent verbal and written communication skills

Must be technically adept/computer proficient to utilize systems software in efficient and effective manner

Good communication/customer service skills.  Strong organizational skills

Ability to work effectively in fast paced environment, use own initiative, effectively multi-task and prioritize

Ability to work independently, maintaining established standards and procedure

Positive and enthusiastic attitude, self-motivated professional advocating the company culture

In an organization with very little turnover, our people are our most valued asset.  The benefits package, eligible first of the month after 30 days from DOH, includes a 401(k) plan with company match, Employee Stock Purchase Plan, health insurance, disability benefits, life insurance, wellness programs, paid company holidays, 3 weeks paid time off (with incremental increases per tenure).

Salary Range: Competitive, based on experience. 

Please submit your resume and salary requirements to This e-mail address is being protected from spambots, you need JavaScript enabled to view it