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Senior Nurse Care Manager

Recruitment #191105-UNCY-317



This position is an internal only posting and is only open to current OHCA staff and contractors.

Act as a clinical nurse specialist to plan, develop and coordinate Care Management for identified members to ensure necessary access to providers and medical services in accordance with the SoonerCare programs. Interface with SoonerCare members, providers, advocacy groups, legislative representatives, other state agencies and OHCA staff to facilitate Care Management for those members. This may include high-risk obstetrics, at-risk newborns, children with special healthcare needs, women in need of treatment for breast/cervical cancer, members with long-term care needs, members with multiple chronic co-morbidities, and complex members requiring highly specialized medical care both in and out of state.  Serve in team-lead role as first-line departmental leadership. 

• Coordinate and facilitate access to medical care for medically complex/special health care needs members identified for Care Management through data mining, incident reports, intra-agency referrals, provider referrals, member self-referrals, legislative referrals, and other state agency referrals.
• Assist departmental leadership in developing processes and procedures utilized by department to facilitate access to care for a wide- variety of SoonerCare members.
• Act as “lead” for associated Care Management team – directing, coordinating, and facilitating Care Management referrals as required.  Senior NCM to personally facilitate the more complex referrals assigned to team.
• Identify, review, research and facilitate removal of barriers to medically necessary care for persons with diverse and complex healthcare needs. Coordinate with community resources/social service agencies within the parameters of the program.
• Document Care Management activities utilizing the clinical case management system and/or other available tools. Interface verbally and in writing with members/families/providers to resolve issues.
• Review and facilitate administrative referrals as related to medically necessary care for members of the OK Medicaid program.
• Review, research and facilitate out-of-state medical care that is determined as medically-necessary and like-care unavailable through in-state providers.
• Review and facilitate transportation, meals and lodging requests as medically-appropriate.
• Coordinate and communicate with community support and social service system to link their services to the delivery of medical care for SoonerCare members.
• Communicate verbally and in writing with DHS county offices and SoonerCare eligibility Unit to resolve eligibility issues of select members.
• Collaborate/communicate with legislative members and their staff as directed by OHCA Government Liaison to resolve issues surrounding medically fragile/medically diverse members’ needs (within the scope of Confidentiality allowed).
• Participate in case staffing meetings as requested by leadership. Collaborate with other agency staff regarding members’ care to ensure coordination of efforts.
• Provide testimony as requested for adjudication of administrative appeals.
• Act as Care Management clinical resource to work with OHCA personnel regarding policy and program issues/concerns related to the complex, special needs of identified/select members.
• Work with internal and external QA processes/personnel to monitor program adherence to state and federal guidelines and contracts, including Provider site reviews.
• Represent OHCA as needed in multiple public forums involving various stakeholder groups, as well as informational seminars and training forums.
• Travel in and out of state as needed.
• Other duties may be assigned.

RN (with current valid license as Registered Nurse in Oklahoma) AND Two (2) years of full time professional clinical experience including one year in an acute care hospital medical-surgical setting AND One (1) year experience as a SoonerCare Nurse Care Manager.

*Advanced nursing degree
*Management/supervisory experience
*Professional certifications
*Experience with persons who are Aged, Blind or Disabled
*Experience with medically fragile/long-term care population


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