- Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
- Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
- Coordinates internal and external resources to meet identified needs.
- Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
- Responsible for performing telephonic and face-to-face clinical assessments for the identification, evaluation, coordination and management of member’s needs, including physical health, behavioral health, social services and long term services and supports.
- Identifies members for high risk complications and coordinates care in conjunction with the member and the health care team.
- Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits.
- Obtains a thorough and accurate member history to develop an individual care plan.
- Establishes short and long term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs.
- The RN has overall responsibility to develop the care plan for services for the member and ensures the member’s access to those services.
- Assists with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible.
- Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on the development of care management treatment plans.
- May also assist in problem solving with providers, claims or service issues.
- 2 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience, which would provide an equivalent background.
- Current, unrestricted RN license in Texas required.
- Travel required within assigned territory.
- Computer literate: MS Word, Outlook, Excel (knowledge highly preferred)
*WARNING : Please beware of phishing scams that promote work-at-home opportunities and which may also pose as legitimate companies. Please be advised that an Anthem recruiter will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for a role with our company. All of our careers require that you first complete an online application.