The Complex Care Nurse/Nurse Supervisor leads a team of clinicians and support staff in the delivery of care coordination and case management services to Medicare Advantage Special Needs Program members. This individual is accountable for the execution of program services according to program specifications to improve care outcomes via interaction with Bright members, their providers and available member support services. This role embodies a philosophy that maintains focus on members’ health, leading by serving as an example to assure members and providers have a positive experience with the services they receive. The Complex Care Nurse/Nurse Supervisor ensures all related initiatives meet all applicable state and/or federal regulatory requirements in addition to corresponding URAC and NCQA standards.

ROLE RESPONSIBILITIES
The Complex Care Nurse/Nurse Supervisor job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Provide leadership and direction to a team of clinicians and support staff, responsible for the development and completion of personal care plans.
• Coordinate with the Clinical Programs team and Program Management team with respect to program design, efficiency, efficacy and member/provider satisfaction.
• Support the development and maintenance of standard operating procedures related to corresponding clinical program functions.
• Collects, organizes, and analyzes data, synthesizing it into an understandable, clear and concise language and provides electronic documentation that meets regulatory requirements.
• Organizes data and reports for ICT meetings on regular basis for their designated population.
• Participate in the development of operating models to execute clinical program solutions, including but not limited to Complex Case Management, Disease Management and Transitions of Care
• Provides guidance to the health coach on topics such as health maintenance, medication management, and disease management
• Collaborate with Provider Relations, Market Management teams and Care Partner representatives in the management of members’ care plans.
• Assists in identifying members’ appropriateness for other programs.
• Reviews medical records for their designated population, as well as lab and medication data, and determines risk level appropriateness.
• Works with outside facilities, agencies, and stakeholders on a routine basis, maintaining positive working relationships to support care coordination.
• Conduct outbound interventions to support to advance member care plans, coordinate care and close clinical gaps.
• Assist the member by arranging follow-up appointments to see the specialist or PCP, as needed.
• Coordinate care for members, with specialists, and assisting with LOA’s for continuity of care issues, and tertiary care needs.
• Refer members to community resources and assist as need to apply for financial and other programs.
• Work with assigned Health Nurse to coordinate home visits as needed, and to coordinate calls to members.
• Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships.
• Supports the administrative efforts of the Care Management Programs department.
• Recruit, hire and train new team members.

SUPERVISORY RESPONSIBILITIES
This position has supervisory responsibilities for members of the Care Management team assigned to supporting Care Coordination and Case Management activities.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
• Bachelor’s degree in Nursing or related field is required
• Five (5) or more years of experience working within Case Management and/or Care Coordination functions
• Two (2) or more years of management experience
• Prior experience with URAC accreditation is desired
• Formal training in Six Sigma management techniques is a plus, but not required
• Bilingual in English and Spanish is preferred

PROFESSIONAL COMPETENCIES
• Ability to evaluate complicated problems and isolate contributing factors
• Capable communicator that can interact with others at multiple levels within the organization
• Leads through influence and example
• Strong operational mindset and use data to draw insights
• Thrives on driving results in a collaborative environment

LICENSURES AND CERTIFICATIONS
• An active, unrestricted Registered Nurse (RN) license is required

WORK ENVIRONMENT
The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel, up to 10% of the time may be required.