Nurse Case Manager - Stapley - Evernorth Care Group

The Nurse Case Management Lead Analyst is an integral member of the Care Management department as part of Evernorth Care Group (ENCG) Patient Health Improvement Team (PHIT).

The PHIT is comprised of care management, clinical pharmacy, behavioral health, and clinician coaches who support ENCG Healthcare Centers and clinicians to improve the health of the patients we serve, with a focus on the management of high- and rising-risk, disease burdened members.

The Nurse Case Management Lead Analyst utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members.

The Nurse Case Management Lead Analyst ensures that program objectives are met and supports patients and physician practices in coordinating patient care through transitions, barriers to care, and education.

This role additionally connects patients to programs and services as available through ENCG, Health Plans benefits, and within the community.

This position manages a panel of patients coordinating services with them and has oversight of the licensed practical nurses (LPNs) on the team.

This role provides disease management and ongoing follow-up of members with Congestive Heart Failure (CHF), Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD) (other conditions may be identified based on patient need).

Reports to : Clinical/Operational Supervisor

Direct Reports : No direct reports, but does provide clinical support and oversight to LPN's and non-clinical staff.

Clinical Responsibilities and Essential Functions

Care Coordination: Coordinates the care of the high-risk, post transition and targeted populations in appropriate, efficient and cost-effective manner.

Assists patient to arrange timely access to services, evaluates social/financial/environmental support adequacy in a culturally sensitive manner.

Care Planning: Collaboratively creates/updates care plans for care transitions, disease management, and other as needed.

Evaluates the effectiveness/relevance of the treatment plan and communicates with the primary care provider and health care delivery team.

Seeks input from health care team members and physicians as able in order to update care plan.

Prepares for and participates in Care Team huddles/meetings to problem solve around highly complex care needs.

Disease Management/Outreach: Initiate new customer and ongoing telephonic connections per protocol for an identified caseload.

Build care relationships among patient/caregivers.

Complete post-discharge calls to all identified patients to facilitate and oversee discharge planning "coordination of care" needs, identifying and closing gaps in care, and providing education within specified timeframes.

Use of Internal/External Resources: Identifies and refers appropriate patients to eligible programs within ENCG and respective Arizona health plans.

Review and inform the patient/caregiver around options f...