Humana Senior Case Manager-RN in Albuquerque, New Mexico

Role: Senior Case Manager, RN Assignment: Medicare Location: Work from home / Virtual

Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.

Assignment Capsule: Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.

  • Work with Medicare members to assess care needs immediately post discharge from clinical setting
  • Work with Medicare members to assess care needs through assessment(s), develop short-term case management care plans goals and refer to specific disease management programs and other health improvement related programs.
  • Collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines and clinical review criteria
  • Perform outbound calls to high-risk members within 72 hours of discharge from acute and skilled care facilities, per program workflow to perform interventions to close clinical gaps
  • Complete member outreach, engagement, and management activities per program workflow and protocols
  • Collect in-depth information regarding a patient’s clinical history, prognosis, treatment plan, response to treatment, access to care, access to personal and community resources, utilization of care, personal coping mechanisms, learning needs and financial constraints. This information provides the foundation for the identification of patient problems and the development of a comprehensive care plan that will address identified needs.
  • Determine specific short and long-term goals, objectives, and interventions with accompanying timeframes based upon evidence-based medicine guidelines.
  • Identify and carry out the relevant interventions that will facilitate the accomplishment of goals established in the care plan.
  • Identify, organize, and integrate the appropriate acute, rehabilitative, sub-acute, homecare, alternative, and community resources needed to accomplish the identified goals in the care plan.
  • Collect sufficient data from all relevant resources to determine the effectiveness of the care plan.
  • Make repeated assessments of the care plans effectiveness at appropriate intervals and make plan modifications, as necessary, to achieve patient goals and improve outcomes.
  • Complete required documentation, including but not limited to: Assessments (initial and on-going), Care Plan (initial and on-going), program referrals, etc.

Role Essentials * Active RN license in the state associate lives * Ability to be licensed in multiple states without restrictions * Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting * Ability to work independently in a virtual/home office environment, under general instructions and with a team * Strong communications both written and verbal * Have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.

Role Desirables * Previous Medicare/Medicaid * Previous experience in case management, discharge planning and/or home health or rehab * CCM * Education: BSN or Bachelor’s degree in a related field * Health Plan experience * Call center or triage experience * Bilingual is a plus

Reporting Relationships: This role will report to a Front-line Leader

Title: Senior Case Manager-RN

Location: New Mexico-Albuquerque

Requisition ID: 190221

Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.