RN Member Triage

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Job Summary

The member triage nurse assesses members for needed resources such as community resources, vendor assistance, case management services, and other interdisciplinary services associated with Clinical Services and Population Health division (CSPH). This position is responsible for answering and routing calls to support the CSPH division, including warm transfers to/from customer service, case management, other support services and resources as appropriate. This position is also responsible for promoting communication through any other omni channels available such as mobile applications.

Requirements

EDUCATION

Bachelor's degree in Nursing preferred.

LICENSING/CERTIFICATION

Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.

Case Management certification preferred.

EXPERIENCE

Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.

ESSENTIAL SKILLS & ABILITIES

Excellent oral and written communication skills

Detail-Oriented

Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.
Ability to prioritize and make sound nursing judgments through critical thinking.
Ability to build collaborative relationships.
Ability to interpret complex documentation.
Ability to work independently with little supervision.

Skills

• Active Listening• Analytical Decision Making• Business Compliance• Collaborative Communications• Conflict Resolution Management• Coordinating Resources• Critical Thinking• Cross-Functional Communications• Cross-Functional Planning• Data Management• Document Recording• Information Interpretation• Interpersonal Relationship Management• Microsoft Excel• Microsoft Outlook• Microsoft PowerPoint• Microsoft Word• Oral Communications• Problem Sensitivity• Public Relations (PR)• Researching• Service Oriented• Support Coordination• Time Management• Written Communication

Responsibilities

• Communication: Serves as a liaison facilitating a collaborative process which includes patients, families/caregivers, physicians, hospital discharger planners, home care providers and other ancillary providers to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.• Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.• Knowledge: Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.• Member Triage: Assesses and resolves gaps in patient care related to chronic health conditions through health education and case management services ensuring gaps are closed in a timely matter. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.• Performs other duties as assigned.• Workflow: Works proactively with referrals from multiple sources to identify gaps in care candidates for case management, explaining services ensuring voluntary agreement of services and maintaining a minimum patient caseload in a timely matter.

Certifications

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.

Originally posted on Himalayas