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Case Manager RN in Richmond, VA at Advantasure

Date Posted: 3/12/2019

Job Snapshot

Job Description


Responsible for utilizing the nursing process in the development of treatment plans, with established goals, implementation, monitoring and evaluation of an assigned patient case loads in order to provide quality care appropriate to clinical needs.


  • Review and analyze referrals from a variety of sources for acceptance into the program
  • Evaluate patient needs, identify and recommend cost-effective health care options
  • Assure member health needs are consistent with nursing standards and practices, provide recommendations
  • Develop and monitor action plans established between member, family and/or designee and physician
  • Develop preauthorization review plans for the review of RN clinical cases
  • Make arrangements for DME supplies, medications, community resources and facilities
  • Educate patient and family and/or designee to processes, care practices, medication(s) and benefits
  • Review prescription drug coverage requests, transplant services, acute organ rejection episodes and/or requests for coverage
  • Prepare documentation, communicate findings and submit recommendations to medical policy, group representatives, and members of the health care team. (i.e. provider, subscriber, family)
  • Coordinate the member appeals process for DOL, PA250/blended cases
  • Ensure clinical outcomes are met preventing future re-implantation
  • Review patient status, educate patient on self management and ensure appropriate levels of post care education are provided
  • Identify potential gaps in member discharge to be avoided through education, empowerment and/or motivational interviewing
  • Clinical review of claims to ensure that correct reimbursement occurs
  • Internal peer review for quality performance
  • May conduct patient home visits to guarantee that the setting is safe and medical services are delivered
  • Continues professional development by attending relevant educational programs at lease annually

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.



Nursing diploma or associates degree in nursing required. Bachelors degree in nursing or related field preferred. Registered Nurse with current Virginia Registered Nurse license required. Certification in Case Management (CCM) preferred. Certification in Chronic Care Professional (CCP) preferred. North American Transplant Coordinator Association certification preferredContinuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.


Two (2) to four (4) years of related clinical experience required. One (1) to three (3) years internal experience preferred.


  • Must have basic computer knowledge, typing capability and proficiency in Microsoft Word and Outlook
  • Knowledge of CM/DM principles, CCM Admin Modules, Care Advance system, Prism, NASCO and P&P
  • VDA, MEDCO, NCSW, Coaches Desktop, COSTCAI, HOTP database where applicable
  • Knowledge of HIPAA, American Disability Act, Clinical ethics, COB rules and Medical Policy
  • Familiarity with InterQual criteria, crises call interventions, evidence based guidelines and alternate care
  • Knowledge of educational assessments and learning strategies
  • Knowledge of medical surgical principals, discharge planning, chronic diseases and clinical programs
  • Ability to negotiate rates with par and non par providers for extra and non-contractual services
  • Ability to develop financial plans
  • Knowledge of current trends in related fields
  • Knowledge of benefits
  • Effective written and verbal communication and feedback
  • Effective organizational skills, ability to prioritize and flexibility
  • Daily travel to assigned on-site facility (Blue Care Connect Case Managers required)
  • Valid current Virginia driver's license and personal means of reliable transportation for nurses on-site (Blue Care Connect Case Managers required)
  • Proof of auto liability coverage for nurses on-site (Blue Care Connect Case Managers required)


Work is performed in an office setting with no unusual hazards.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.



  1. Knowledge and understanding of the facility and provider environment as it relates to transplantations
  2. Responsible for the collaborative team input and efforts in the development, implementation, and follow up of cases within the Human Organ Transplant Program.
  3. Responsible for monitoring transplant programs with the Medical and Care Management Operations area. This encompasses all specified solid organ transplants and bone marrow/peripheral stem cell transplants.

Care Coordinator/Discharge Planner

  1. Improve overall member's health status through avoiding unnecessary hospital re-admissions by focusing on medication knowledge, adherence/reconciliation, diagnosis and de-compensation with timely follow up.
  2. Advise appropriate referrals to community resources, mental health services, substance abuse services and financial support services based community knowledge of disease-specific services and resources.
  3. Knowledge of the URBMT process
  4. Concurrent review process
  5. Medicare Advantage process, including Alere, CCCM, and Kepro
  6. Knowledge of Provider Search
  7. Two (2) years utilization review, discharge planning, case management, home care preferred
  8. Experience in a managed care environment preferred
  9. Alternative care settings in home care, skilled nursing facilities, sub-acute, hospice and home infusion

Chronic Condition/ Disease Management Specialist

  1. Chronic Care Professional, CCP certification preferred
  2. Experience in med surgical, preventive care, diabetic education, homecare, critical care and public health
  3. Knowledge of Disease Management principles preferred
  4. Assess member's knowledge and understanding of chronic conditions (Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Ischemic Heart Failure, Diabetes and Asthma) and its severity.
  5. Familiarity with quality management process and customer focus
  6. Chronic Conditions (CCP) principles
  7. Knowledge of Blue Health Line
  8. Knowledge of Member Health Records
  9. Demonstrated knowledge of managed care principles, UM/QM programs, claims databases required
  10. Related experience in ambulatory care, discharge planning or home health nursing preferred
  11. Public health, epidemiology or health services administration experience preferred
  12. Provide telephonic support to members enrolled in disease management programs.
  13. Lead workgroups to develop and implement disease management programs