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Complex Case Manager RN

S&D Recruitment
Los Angeles, CA
November 08, 2019


Required skills & experience:

1. Active, unrestricted RN (BSN preferred) license in California (Willingness to obtain additional state licenses as needed)

2. Utilization knowledge on Part A, Part B and part D Medicare.

3. Medicare/ Medicare Advantage experience is strongly preferred, but if no Medicare Advantage experience then candidate needs to have Complex/Case Management experience.

4 Knowledges of HEDIS

5. Two years case management at a managed care plan or provider organization and knowledge of the evidence based guidelines for the main chronic conditions-HTN, CAD, Heart Failure, Diabetes, CKD and COPD.

6. Ability to understand CMS guidelines

7. Understanding of the basic principles for OSHA, CLIA, HIPAA and AHCA.

What you need to know:

• RN has to be bilingual

• This location covers mostly Orange County

• Adaptability is key. Oscar moves quickly and things change. Candidate must be able to adapt and pivot.

• RN must be Self-motivated---this role is remote and this role requires RN to be able to keep themselves motivated and on track with daily responsibilities.

• The assigned Registered Nurse (RN) will operate within the company’s Clinical Care Delivery department providing onsite and telephonic care management services to Medicare Advantage individuals identified as “high risk members”.

• Serve as the primary point-of-contact for a selected group of Medicare Advantage members and their families.

• Will travel between the office, member's homes and acute and subacute facilities.

• Will participate in twice weekly meetings with Medical Director to review member’s progress, update the plan of care as needed.

• Works in collaboration and continuous partnership with chronically ill or "high-risk" patients and their family/caregiver(s) in a team approach to:

-Reduce emergency room utilization and hospital readmissions.

-Promote timely access to appropriate care.

-Increase utilization of preventative care.

• Initiates onsite hospital visits/rounds as needed to assess patient progress and meet with appropriate members of the patient care team.