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On Site Bilingual Nurse Case Manager I or II (Pediatric/PEDS/ER) - Job Family

Location: Miami Gardens, FL
JobFamily: Medical
Req #: PS66774
Date Posted: May 23, 2022

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Description:

Description

SHIFT: Day Job

SCHEDULE: Full-time

Your Talent.  Our Vision.  At Simply Healthcare, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. We are a Florida licensed health maintenance organization that serves individuals enrolled in Medicaid and/or Medicare programs, Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve. 

Location: On-site at a Pediatric Hospital in Miami, Florida (This is not a work-from-home position)

Nurse Case Manager I, or II (Job Family) *
Hours:  9:00 am - 6:00 pm EST (Monday - Friday)

*Please note: This position may be filled at either the Nurse Case Manager I, or II. The Hiring Manager will determine the level based upon the selected applicant's skillset relative to the qualifications listed for this position. *

Job Description - Nurse Case Manager I, & II
Responsible for performing care management within the scope of licensure for pediatric members with complex, chronic care, and special needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans/interventions designed to optimize member health care across the care continuum. This position requires the Nurse Case Manager to perform duties on-site, at a pediatric hospital for discharge planning.

Primary duties may include, but are not limited to: 

  • Ensures members access to services appropriate to their health needs. 
  • Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. 
  • Implements care plan/interventions by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements as applicable. 
  • Coordinates internal and external resources to meet identified needs. 
  • Monitors and evaluates the effectiveness of the care management plan and modifies as necessary. 
  • Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans/interventions. 
  • Negotiates rates of reimbursement, as applicable. 
  • Assists in problem-solving with providers, claims, or service issues. 
  • Assists with the development of utilization/care management policies and procedures. *
  • Recognize those high utilizer members (2+ last 12 months), identify the most appropriate and cost-effective resources to support their needs, and establish community linkages to ensure a safe care transition and an effective treatment other than an avoidable visit to ED.
  • Educate Simply Medicaid Members and family members regarding access to and availability of non-emergent services when appropriate such as PCP, Nurse helpline, and urgent care.
  • Meet Agency and Plan expectations by enhancing the CC of the services between NCH and the Plan to reduce potentially preventable admissions, readmissions, and emergency visits.
  • Completion of the HRA for all members especially those new to the Plan with Asthma, DM, SMI, or pregnant.
  • Stimulate telehealth as another option if available from PCP/Specialist/hospital.   
  • Education about the appropriate access and availability of non-emergent services as applicable as well as the member’s plan benefits. Distribute Plan approval Educational Materials as applicable. 
  • Direct linkage of members that needs ongoing coordination for special medical/behavior/social care conditions to our Plan especially those that have been UTC.
  • Update the Contact Information as necessary. 
  • Assess SDOH/Behavioral needs. Provide the Plan/Community resources available. 
  • Incorporate referrals and follow-up phone calls following day for high-risk members to improve member experience results as well as reduce unnecessary visits. 
  • Assesses/Identify the barriers to primary care access: 
    • PCP as a primary option (i.e.did the member know if the PCP has any special hours/telehealth?) 
    • Nurse helpline  
    • Urgent Care

*Nurse Case Manager II additional duties 

Simply Healthcare Plans is a Florida managed health care provider that serves Medicare and Medicaid members. Through our Clear Health Alliance organization, our health plan also serves Floridians who are eligible for HIV/AIDS Medicaid specialty health plan services. Along with our sister plan, Amerigroup Florida, we serve more than 600,000 Floridians who are members of our Medicare and Medicaid plans. Across the nation, our family of health plans serves nearly 40 million members, and 1 in 8 Americans is served by our family of companies. Our health plan members are assured care that is not only accessible, but also accountable, comprehensive, integrated, and patient-centered. Each and every day, members of our team can be found in Florida communities, listening to our members, interacting with our health care providers and partnering with community-based organizations to execute health education initiatives. Our goal is to ensure members and entire communities are empowered to become active participants in their health care and sustain healthy lifestyles. To learn more about Simply Healthcare Plans, visit www.simplyhealthcareplans.com.

 

Qualifications

Required Qualifications - Nurse Case Manager I

  • Requires BA/BS in a health-related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. 
  • A current, unrestricted RN license in the state of Florida is required.
  • Multi-state licensure is required if this individual is providing services in multiple states.

For URAC accredited areas the following applies: Requires BA/BS and 3 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background. Current and active RN license required in the state of Florida. Multi-state licensure is required if this individual is providing services in multiple states. 5 years of experience, certification as a Case Manager from the approved list of certifications, and a BS in a health or human services-related field preferred.

Required Qualifications - Nurse Case Manager II

  • Requires BA/BS in a health-related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. 
  • Current, unrestricted RN license in the state of Florida is required.
  • Multi-state licensure is required if this individual is providing services in multiple states. 

For URAC accredited areas the following applies: Requires a BA/BS and 5 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background. Current and active RN license required in the state of Florida. Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager from the approved list of certifications and a BS in a health or human services related field preferred.
 

Preferred Qualifications - Nurse Case Manager I, or II

  • Bilingual in Spanish and English is critical in this role and strongly preferred. 
  • Min. of 3 years of clinical experience, in any of the following areas: Pediatrics, Emergency Room (PEDS or both Adults and PEDS) is critical in this role and strongly preferred.
  • Certification as a Case Manager is preferred.
  • Prior managed care experience is strongly preferred.
  • A fundamental understanding of case management is highly desirable.
  • Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
  • Computer skills: experience working with MS Word, Outlook and Excel, SharePoint. (The associate will receive training on company-specific applications, however, they must be comfortable working on a laptop with web-based applications. If you are not computer savvy this may hinder your ability to be successful in this position.)

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs, and financial education resources, to name a few.

The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state, and local laws.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.

Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.