RN Nurse Case Management Lead Analyst - Pathwell and Specialty Care Options (SCO) - Work from Home,

Please note: This position is open to Registered Nurses who are licensed and RESIDE in California.

Summary Description of Position

Manages a caseload of customers that require specialty drugs, evaluating the need for alternative services and as appropriate; assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's healthcare needs.

Through communication and available resources, the Case Manager promotes care coordination, provider collaboration, quality case outcomes, and provides quality, cost effective alternatives to care as appropriate.

As an owner of cases, the Case Manager performs clinical review of medical specialty pharmacy services, coordinates transition of care, product rate negotiations, and accurately calculates medical cost savings.

Case Managers performs case management evaluation to identify any clinical needs, social determinants of health needs, discuss programs and services available with referrals as appropriate, and coordinates care and closes gaps through collaboration with customers, treating physicians, and servicing providers.

Major Job Responsibilities and Required Results



* Obtains informed verbal consent from customers for case management services


* Establishes a collaborative relationship with the client (plan participant), family, physician(s), facilities, specialty pharmacies, and other providers to determine medical history and current status to assess the appropriate level of care and options for alternative care.


* Assistance in the identification of member health education needs through health assessment activities


* Utilization of health prevention guidelines and general health and wellness strategies to achieve goals in the overall health of members.


* Perform research on relevant topics in health promotion and disease prevention, as required for specific members


* Consult with and assist team members in cases where a member's behavioral health or emotional issues are impacting their ability to set and/or achieve goals


* .


* Educate and refer members on available internal and external health resources


* Provides 1:1 telephonic coaching to members around their behavior change to improve health status, reduce health risks and improve quality of life.


* Assesses readiness to change and implements actions to assist members in moving through stages of change to reach their goals


* Work with members to identify and set personalized health improvement plans and goals and support members in achieving those goals.


* Promote consumerism through education and health advocacy.


* Assesses member's health status and treatment plan and identifies any gaps or barriers to healthcare.

Establishes a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and pr...