Nurse Case Manager Remote -- MediGold Health Plan

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more. We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing.

The RN Case Manager MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member’s family and other resources as appropriate. Assists in the implementation of Case Management software along with the Plan’s UM and QM Program and the review of the Plan’s Medical Management Plan.

Coordinates with case management resources to assure development and documentation of a treatment plan for members who meet the Plan’s guidelines for Case Management and communicates the plan to the member’s PCP and other members of the care team. Completes an initial assessment of the member’s health status, including medical history, medications, symptoms, degree of support from family & friends, and current treatment prescribed by the member’s physician. Consults with member to set negotiated goals and determine the frequency of interaction. Provide telephone follow up at the frequency agreed upon and teaching to promote goal attainment as well as providing educational materials appropriate for that member’s condition. Assist member to be an advocate for their healthcare and assist with formulating questions to ask the physician, as well as how to respond to common symptoms they might experience. Participates in designated committees and task forces at the direction of the Supervisor and Sr. Director of Medical Management. Coordinates with the utilization review, case management, discharge planning staff within network facilities. Creates and maintains a case management database of referrals and treatment plans for Members. Coordinates with Medical Director/Associate Medical Directors on case-specific issues. Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues. Conducts inpatient concurrent review. Documents and communicates to QM staff appropriately all identified quality concerns related to Members.