Coordinates the care and services of Long Term Care members across the continuum of illness. Promotes effective utilization and monitors health care resources. Assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes. Works with the PCP, member's family, Supervisor/Manager of Care Management to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Member.
Department: Long term Care
Reports to: Mgr, Care Management
Additional Responsibilities:Candidate Education:
- In conjunction with the PCP, member, member's family, and other pertinent members of the Interdisciplinary Care Team (IDT), CM completes a comprehensive assessment and develops a Person Centered Service Care Plan utilizing clinical expertise to evaluate the member's need for alternative services. Assesses short-term and long-term needs and establishes case management objectives.
- Manages 75 to 100 active cases based on case intensity and acuity.
- Responsible for Utilization Management and uses prescribed criteria to provide timely, appropriate, and medically necessary service authorizations.
- Interacts continuously with member, family, physician(s), IDT members, and other providers, utilizing clinical knowledge and expertise to determine medical history and current status. Assesses the options for care, including use of benefits and community resources, in order to update the Person Centered Service Care Plan.
- Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
- Maintains accurate records of care management activities in the EMMA system, using clinical guidelines.
- Coordinates community resources with emphasis on medical, behavioral and social services. Applies care management standards and maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
- Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
- Participates in monthly chart audits.
- Performs special projects as assigned.
- Preferred A Bachelor's Degree in nursing or related field
- Required A Bachelor's Degree in Nursing or related field may be required in certain states based on specific contracts
- Required 2 years of experience in a clinical acute care position(s), preferably in home health, physicians office or public health
- Required 1 year of experience in care/case management
Licenses and Certifications:
- Intermediate Ability to drive multiple projects a plus
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
- Intermediate Demonstrated negotiation skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to implement process improvements
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Preferred Certified Case Manager (CCM)
- Required Intermediate Microsoft Excel Intermediate knowledge and skills of MS Office including Excel, Word and Outlook Express
- Required Intermediate Microsoft Word
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Outlook
- Preferred Other Bilingual skills