Clinical & Nursing
RN Case Manager
Albuquerque, NM, United States

It’s Time for A Change …

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard, and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely—70.3% in year-over-year revenue growth in 2017. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

True Health New Mexico launched on January 1, 2018 as a wholly owned subsidiary of Evolent and focuses on improving the health and well-being of its health plan members by making sure their care is coordinated at every level. Within the Evolent ecosystem of provider-centric solutions for value-based care, our True Health New Mexico team focuses on keeping people healthy, lowering premium costs, and delivering appropriate levels of care at the right time to help health plan members avoid unnecessary hospital stays and emergency department visits. True Health New Mexico serves small and large businesses across New Mexico. Together, Evolent and True Health New Mexico are harnessing the power of our combined organizations to improve the health of New Mexico. Join the True Health New Mexico team and put your passion to work for transforming the U.S. health care landscape for patients, providers, and payers.

Who You’ll Be Working With:

You will be working in the True Health New Mexico office as a part of the Case Management Team which includes physicians, registered nurses, social workers, pharmacists and case management coordinators.  You will report to the Manager of Case Management.


What You’ll Be Doing:

Utilizing the case management process, the Case Manager is responsible for providing coordination of services across the continuum of care to members and their families identified as having chronic diseases. You will connect with members and families/caregivers on the phone and/or in person at the hospital or in the physician’s office.  The case manager assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/family and other members of the healthcare team.

  • Identifies chronic or catastrophic cases and initiates intensive behavioral health/medical complex case management according to the program guidelines.
  • Follows the case management process:
    • Telephonically contacts members and their family/caregivers to conduct various assessments (medical/psychosocial/behavioral health). Evaluates member/family strengths, health behaviors, and resources.
    • Analyzes data obtained from the health risk assessment (HRA) and other reports generated for identifying at-risk members.
    • Develops care plans, which include identified problems and goals customized to meet the specific personal and age-specific needs of the member.
    • Coordinates with members, families, and caregivers to help resolve barriers to care.
    • Researches clinical criteria as indicated.
    • Monitors ongoing care and movement toward goals through interaction with the member, family/caregiver, and providers.
    • Acts as a bridge between healthcare personnel, members, and their family/caregiver for ensuring efficient healthcare services and follow-up.
  • Assesses and triages immediate health concerns. Intervenes with at-risk members to avoid unnecessary hospitalizations.
  • Advocates and serves as a liaison between healthcare providers, members, and families/caregivers.
  • Maintains awareness of community resources and other resource availability for services outside – or complementary – to benefit structure.
  • Provides education materials related to members’ disease process/diagnoses. Promotes and maintains member health through teaching and appropriate rehabilitative measures. Helps members learn appropriate self-care techniques.
  • Communicates with providers and support staff as needed (community health workers, social workers, and/or inpatient case managers).
  • Takes inbound calls and places outbound calls as needed to manage member needs.
  • Solicits feedback from providers and patients on satisfaction with case management services.
  • Assists in the identification and reporting of potential quality improvement issues.
  • Participates in clinical outcomes monitoring, follow-up, and health plan performance improvement initiatives.
  • Maintains confidentiality of member information in accordance with HIPAA regulations.
  • Remains flexible and responsive when changes occur in patient activity and workload.
  • Attends and participates in staff meetings, required in-services, and other meetings as required.
  • Collaborates with other departments and serves as a liaison to improve communication and customer service.
  • Other duties as assigned.

 

The Experience You’ll Need (Required):

  • Licensed registered nurse; will consider LISW with at least 5 years of related health plan experience.
  • Working knowledge of case management principles and procedures based on nationally recognized standards of case management.
  • General knowledge of medical necessity determination processes and guidelines, as well as New Mexico regulatory requirements for utilization management.
  • Knowledge of National Committee for Quality Assurance (NCQA) standards for utilization management, disease management, and complex case management.
  • Exceptional service focus.
  • Effective analytical, verbal, and written communication skills.
  • Ability to work independently and in a team environment.
  • Ability to manage multiple tasks.
  • Good working knowledge of relevant PC applications, especially Microsoft Word software and Web-based applications.
  • Energized by, and comfortable with, rapidly evolving organizational needs and environment.

Finishing Touches (Preferred):

  • Certified Case Management credential
  • Bilingual speaking, writing, and reading skills. 

Evolent Health is an equal-opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

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