Job Description

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose

Responsible for daily case management and care coordination for health plan members. Ensures a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes.

Minimum Specifications

Education

• Must be a graduate of an accredited school of nursing.
• Bachelor’s degree in nursing is preferred.

Experience

• Three years of experience nursing in a clinical or medical management setting.
• Three years of managed care case management experience is preferred.

Equivalent Education and/or Experience

• May have an equivalent combination of education and experience to substitute for the experience requirements.

Certification/Registration/Licensure

• Must have and maintain current, valid RN license or temporary RN license from the Texas Board of Nursing, or valid Compact RN license.
• Prefer Certified Case Manager (CCM) or American Nurses Credentialing Center (ANCC) RN-BC credential in case management.

Skills or Special Abilities

• Proficient in medical and managed care terminology.
• Competent in application of case management standards.
• Familiar with auditing processes and regulatory/accreditation requirements (TDI, NCQA, URAC, CMS).
• Prefer working knowledge in the use of Microsoft Word and PowerPoint.
• Professional verbal communication skills with internal and external audiences.
• Ability to manage multiple deadlines and time constraints.
• Adept at applying critical thinking skills and analysis.
• Professional writing skills.
• Ability to be flexible and work in a high growth environment.
• Excellent organizational skills and attention to detail.
• Aptitude for interpreting reports and using Excel spreadsheet functions, such as formulas, graphs, and formatting.
• Ability to analyze and resolve complex and conflicting information.
• Proficient in meeting NCQA care management standards.
• Knowledge of Federal and Texas Medicaid regulations.
• Ability to define care management reporting requirements.
• Adept in use of case management software.
• Ability to develop and foster positive interpersonal relationships to effectively communicate and engage all levels of stakeholders.

Responsibilities

1. Provides input into and follows the Case Management and Quality Management plans and assists with data collection for reports.
2. Adheres to CMSA’s Standards of Practice for Case Management and complies with health plan policies.
3. Participates in self-audits and peer reviews to ensure compliance with regulations, standards, and departmental policies and provide feedback for the Case Management training program.
4. Conducts Case Management activities according to model of care, program description and policies and procedures to provide timely, quality care and services to members.
5. Gathers available clinical information for new and existing cases, performs case reviews based on policies and assessments, and refers to medical director as per policy.
6. Completes case interventions according to time and completeness requirements and documents all actions and decisions in the Case Management software system.
7. Maintains directory of community resources.
8. Functions as liaison with member's providers.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.