Job Description
Job Title Managed Care Case Manager
Location San Antonio,  TX
Other Location
Summary:   This nursing role focuses on improving quality of care /continuity of care and reducing utilization costs.  Provide Case Management to GMG capitated patient population:  focus on complex care patients who are high cost, have frequent inpatient or ER encounters, and/or patients who need added expertise to guide them through a complex treatment plan.  

  1. Maintain accurate database of GMG complex care patients.   Review High Risk census weekly  to ensure it reflects appropriate high cost patients, those who frequently have hospital admits/ER visits, and other highest risk patients for case management. 
  2. Stratify the patients in team meetings to define those needing home visits by Complex Care RN/ MSW, and define the frequency of telephonic contacts for each patient on census.  
  3. Place timely calls to complex care patients to assess their health status, ensure the treatment plans are being carried out, perform teaching, and monitor outcomes.
  4. Arrange appropriate acute care and follow up care with PCP, Intake, and other GMG Providers or Preferred Providers. 
  5. Keep PCP, clinical and complex care team members informed of pertinent findings/issues.
  6. Follow daily hospital census; help update PRN. 
  7. Participate in physician communications (email, meetings, etc)  to keep tabs on clinical picture/plan for patient.
  8. Ensure that patients have prompt Hospital Follow up appointments to help prevent readmission.  Assess discharge status, level of understanding and  compliance;  monitor attendance/ follow up on ‘no shows’ and cancellations.
  9. Attend Patient Care Committee and High Risk Team meetings to provide follow up case management and other special care needs defined during PCC and HR Mtgs.
  10. Assist with other patients as needed to set up complex services that are needed acutely:  SNF, Custodial Care, Psychiatric services, IV treatments, etc
  11. Review HH/DME forms and ensure services are authorized before providers sign/fax.
  12. Track non compliance events and send out appropriate correspondence to patients and plans.
  13. Document appropriately in GMG computer systems, complex care database and other associated systems.
  14. Successfully meet production goals
  15. Exercise tact and courtesy when dealing with patients, visitors, physicians and co-workers.
  16. Able to work efficiently under pressure.
  17. Maintain strict confidentiality.
  18. Other duties as assigned.
Education and Experience Graduation from an approved practical nursing program.  Must be state-licensed practical nurse with a minimum three year of LVN experience, clinic experience preferred.  Prior managed care experience preferred.    Must have knowledge of medical terminology, understanding of ICD-9 coding.   Must have excellent customer service skills.
Computer Skills: Knowledge of Word Processing software, database software, spreadsheet  and Internet software
Supervisory Responsibilities:  This job has no supervisory responsibilities.
Work Environment:  Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment.  Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a clinic environment.
Physical Demands:  Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus.
Required Skills Nursing
Customer Service
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