Utilizes care coordination tools, criteria and protocols to provide outpatient care members with chronic and acute conditions the support, education and assistance in the prevention and/or maintenance of their disease and/or health and wellness state; increase member compliance with treatment plans; engage community resources to support the members' optimal functioning and improve collaborative coordination of care to affect waste and inefficiency.
Reports To: Sr., Mgr., Clinical Care
Department: Health Services
Position Location: Houston, TX 77081
Additional Responsibilities: Candidate Education:
- Provide telephonic follow up with members for case management services once discharged from facility, or once member has been stratified at a level requiring case management follow up.
- Facilitate provider contact as needed to coordinate member's care needs. Initiates appropriate referrals and inputs authorizations as needed for members under case management.
- Identify high risk members for disease or case management needs and works with member, physician and other Health care providers to establish a plan of care to meet the member's individual needs. This would result in a call to the identified member to explain the program, assess needs, educate member regarding the disease as appropriate.
- Identifies and escalates member cases with complex medical needs to Manager and/or Medical Director.
- Instruct the member on how to access the program resources, suggest and/ or arrange follow-up including mailing of educational materials, contact with community resources, facilitate physician visits.
- Documents all contacts in the Health Services clinical documentation system.
- Manage members in current disease management programs, completing and revising as necessary, the information in clinical documentation system.
- Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in the Universal American Corporate and department policies.
- Identifies potential quality of care issues and refers to the quality department.
- Assists in the implementation of specific strategies that improve the quality and outcomes of care.
- Educates members and facilitates HEDIS gap closure.
- Performs all other duties assigned.
- Required A High School or GED
- Preferred A Bachelor's Degree in nursing or related field
- Required 2 years of experience in utilization management and/or case management experience within a hospital, home health setting or managed care company
- Required Other prior experience working with a geriatric population
Licenses and Certifications:
- Intermediate Ability to drive multiple projects
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to work independently
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate 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 implement process improvements
A license in one of the following is required:
- Required Other Current unrestricted LPN/LVN state license
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook