SNP

Arcadian was founded by a physician over 13 years ago, and we are dedicated to improving the health of our members by providing access to high quality, cost effective health care to over 70,000 members in 15 states across the country.


Arcadian’s
Health Plan organization is a community-based local network, providing coordinated care to our members in small to medium-sized communities across the United States. We offer a variety of value-oriented Medicare Advantage health plans and we exercise the utmost standards of dignity, compassion, understanding and respect for our members.


Mission
Statement

Arcadian is dedicated to consistently meeting or exceeding expectations of our members by providing access to high quality coordinated health care at a cost effective price.

Our Core Values

·         We believe in attracting and retaining the best people since they are critical to our success in delivering flawless service to meet or exceed expectations of our members and CMS

·         We hold ourselves accountable in our results as individuals and as members of the Arcadian Team

·         We believe in an entrepreneurial and competitive spirit

·         We apply honesty, integrity and respect in everything we do

·         We embrace the richness of our diversity and remaining open to new ideas and contributions from our team


JOB SUMMARY:

The Case Management (CM) nurse position is critical to the success of Arcadian Health Plan and as such is responsible to assure that members have access to quality, cost-effective health care and assists in the assessment, coordination, and monitoring activities necessary to accomplish this. The CM nurse is responsible for the assessment of potential case management cases, developing member specific goals, interventions and recommendations, initiating service coordination and the implementation of the case management process as well as ensuring the integrity of high quality case management services.  The CM nurse also provides reports to market leaders and represents the health plan with positive and professional working relationships in the health care community. The CM nurse will identify cases that require case management with reasonable expectation of a return on investment as documented by established measurable, patient specific goals including timeframes for revaluation and response to services. The CM nurse will work collaboratively with the Resource Nurse/Resource Physician/Medical Director and MSW in the management of these members.  The CM nurse will also work collaboratively with both the internal and external physician to ensure that consultations and medical necessity decisions are made in a timely and efficient manner.  Additionally, the Case Management Nurse will provide input to the Clinical Care Committee meetings and assist in the preparation of meeting materials and reporting requirements. This position is multifaceted; requiring a diverse set of management and organizational skills such as self-motivation and the ability to work under pressure, effectively manage multiple priorities, meet deadlines and function in a team environment. The CM nurse must be able to work congenially and collegially with a wide variety of individuals both internal and external while maintaining the highest level of confidentiality and professionalism at all time. Strong oral and written communication skills as well as highly effective public relations skills are essential. The position requires strong computer skills.             

 

QUALIFICATIONS:

 

Education: 

·         Current, valid nursing license (RN) in the state of residence. Ability to obtain valid nursing license in other states that Arcadian Health Plan may enter the Medicare Advantage market.

·         Bachelor of Science Nursing degree preferred. 

·         CCM preferred.

 

Experience:   

·         Minimum of 2-5 years of Home Health, Discharge Planning, Case Management, Utilization Review and/or recent nursing experience.

·         Minimum 2 years CM experience in an HMO or IPA/PMG setting

·         Experience in meeting preparation, meeting facilitation, setting agenda’s and keeping minutes

·         Experience with computer and software programs (e.g.; Microsoft Word, Excel) and the internet

·         Experience applying InterQual or other practice management guidelines

·         Experience with case management of the senior/SNP population

·         Experience with Medicare billing practices, DRG’s HHRG’s, RUGs, CPT/ICD-9CM coding as it relates to the authorization processes

·         Familiarity with Code of Federal Regulations (CFR), Medicare Special Needs Plan Model of Care, Medicare Advantageand State Medicaid Regulations

·         Familiarity with the CMS website, CMS Manuals, and CMS audits

 


Skills:

·         Competent administrative and organizational skills, ability to multitask and set priorities

·         Effective communication style (oral and written) with proven ability to positively influence behavior and arrive at a “win-win” resolution

·         Strong clinical skills and judgment necessary to interpret and follow medical guidelines and provide patient education supporting the care plan set forth by the medical home.

·         Ability to research complex issues as it relates to Medicare benefits and coding/billing practices synthesizing the information, concisely communicate either verbally or in writing findings and recommendations.

·         Strong computer skills, including the internet, ability to quickly research complex issues and effectively work in a computerized case management system/queue environment with minimal paper

·         Independent thinker, logical, strategic, with an attention to detail

·         Professional demeanor

·         Ability to:

·         creatively solve problems

·         perform data analysis and prepare reports

·         travel (e.g.; driving to local hospitals, flying)

·         assist with sales/marketing presentations

 

Job Duties and Responsibilities:

·         Perform complex case management via phone or on site as needed on cases identified to develop, implement and review care plans with short and long term goals including anticipated outcomes, rationale for ongoing case management process and referral sources while identifying and removing barriers to implementation.

·         Practice case management in a manner that respects the diversity of the member as well as results in a high degree of satisfaction with the case management interventions as interpreted by the members/families and both internal and external providers.

·         Work collaboratively with all members of the health care team, including discharge planners at the affiliated hospitals and community services that may be available

·         Promote early and intensive treatment intervention in the least restrictive setting.  Apply approved UM decision criteria to the management of complex and chronic cases.

·         Utilize multidisciplinary clinical, rehabilitative and support services and arrange comprehensive and appropriate resources for members.

·         Assist Medical Directors in preparing materials for Arcadian Health Plan Clinical Care Committee meetings

·         Oversee and develop the case management caseload resulting in cost efficient utilization of services, continued quality of care and meeting federal guidelines.

·         Review of managedcare.com and all other necessary reports in order for early case management identification, status and outliers.

·         Self monitor daily productivity in order to meet the department standard for case management time.

·         Demonstrate appropriate documentation for case management activities in a timely, competent and error free manner.

  

Physical Requirements of the Position:

·         Sitting:  The essential functions of this job are performed while seated at a desk or work station for at least 50% of scheduled work hours

·         Standing and walking: The essential functions of this job require the ability to move from one location to another either by walking, driving, or flying.

·         Hearing:  Must be able to receive and send detailed information through oral communication and clearly understand people speaking in her/his presence and over the telephone

·         Speaking:  The essential functions of this position require speaking and communicating English in a clearly understood voice at all times during scheduled work hours

·         Fingering and repetitive motions:  Functions of this position require a fair amount of movements of the wrists, hand, fingers in the use of office equipment such as phones and computer keyboards

·         Vision:  The essential functions of this position require the ability to clearly see detailed information via written manuscript and or computer

·         Lifting:  A function of this position requires the ability to lift at least twenty-five pounds on an occasional basis

·         Availability by phone, fax, or pager when out of the office

·         Ability to travel by plane or car


Arcadian offers a competitive compensation package that includes:

·         PPO or HMO Medical Health Coverage

·         Dental Coverage

·         Vision Service Plan (VSP)

·         Flexible Spending Accounts

·         Basic Life Insurance/ADD

·         Voluntary Life Insurance/ADD

·         Short-term/Long-term Disability

·         401(k)plan

·         Paid time off

·         8 National Holidays observed

·         Employee Assistance Program

·         Employee Referral Bonus Program

·         Direct Deposit


Arcadian is an Equal Opportunity/Affirmative Action Employer; M/F/D/V.