Job Description

Job Description

Job Description

The Nurse Case Manager coordinates healthcare services, benefits, and resources for individuals eligible for OCHN’s Complex Case Management Program and/or OCHN/Medicaid Health Plan Care Coordination. The Nurse Case Manager collaborates with providers and individuals served to assess, plan, implement, coordinate, monitor, and evaluate options and services to meet individuals’ health needs through available resources to promote quality and cost-effective outcomes. Additionally, the Nurse Case Manager provides content expertise related to integrated healthcare to the OCHN provider network and supports OCHN in adhering to regulatory requirements and maintaining accreditation.

Essential Functions

Under direction:

• Work with a multi-disciplinary team to establish shared care plans and coordinate care through the health care continuum. 
• Research and resolve issues related to benefits, services, coordination of benefits, and Mental Health and Substance Abuse care coordination.
• Actively promote communication between individuals served, family, providers, Medicaid Health Plan, and all parties involved.
• Identify, document, and resolve quality of care issues.
• Promote and engage in positive and constructive daily teamwork.
• Conducts telephonic healthcare assessments with individuals deemed “high risk” or “at risk”
• Utilizes population health and other healthcare information to refer individuals to targeted health and wellness services.
• Makes referrals for individuals deemed “high-risk” and /or “at risk” to receive appropriate medical and behavioral health services.
• Utilize multiple applications to access and organize data for analyses to guide population health management activities.
• Analyze data and management reports.
• Participate in workgroups and committees with OCHN, Medicaid Health Plans, and provider organizations.
• Complete all documentation in accordance with Medicaid and NCQA regulations.
• Perform other duties as assigned, which could include, but is not limited to community-based work (such as providing assistance within our provider network as needed).

Job Requirements and Qualifications

Education:

• Bachelor's Degree in nursing, allied health, business, or related field preferred.

Training Requirements (licenses, programs, or certificates):

• State of Michigan license, certification and / or registration as a Nurse (RN) required.
• Certified nurse case manager strongly preferred.

Experience Requirements:

• At least three years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
• One (1) year experience in a managed care environment preferred.

Preferred Requirements:

• Knowledge of the Michigan Mental Health Code.
• Understanding of Medicaid rules and regulations.
• Knowledge of NCQA strongly preferred.
• Understanding of case management and care coordination.
• Understanding of managed care philosophy, policies, and procedures.
• Understanding of use of clinical guidelines and criteria for medical necessity, setting/level of care.
• Understanding of population health management components and strategies.
• Knowledge of medical terminology and ICD10 and DSM5 diagnoses.
• Knowledge of State and Federal HMO regulations.
• Knowledge of word processing software.

Job Specific Competencies/Skills:

• Leadership style that is team driven, open, accessible, and transparent.
• Excellent customer service and interpersonal skills, including the ability to interact with internal and external customers at all levels of organizations.
• Excellent written and verbal communication skills.
• Excellent documentation skills.
• Ability to use multiple applications to access data for analysis.
• Ability to develop and implement interventions to improve health outcomes for individuals based on analyses of population-level.
• Strong problem-solving, analytical, and decision-making skills.
• Strong organizational, planning, and implementation skills.
• Ability to manage multiple projects and timelines.
• Ability to effectively present information both orally and written to administration, the public and/or Board of Directors.
• Maintains confidentiality and compliance standards.
• Flexible.
• Cultural competency expertise and orientation.
• Ability to work collaboratively with individuals receiving services and their family, friends and allies, representatives from health plans, provider staff, primary care staff, and others in the healthcare industry.

Oakland Community Health Network’s Core Competencies:

• Interacting with others in a way that gives them confidence in one’s intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity/Building Trust)
• Making customers and their needs a primary focus of one’s actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served. (Customer Focus)
• Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning)
• Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards)
• Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)

Additional Information

(Travel required, physical requirements, etc.):

• Must have available means of transportation to and from OCHN and for required offsite meetings or site visits.
• Must be available for meetings and events which may occur outside of standard office hours.
• Work performed primarily in an office environment.
• Hybrid (onsite/remote) work schedule available.
• The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation.

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees' differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics

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