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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.
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. 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.
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.
Document 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.
Performs all other duties assigned.
Additional Responsibilities:Candidate Education:
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
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 Demonstrated interpersonal/verbal communication 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 implement process improvements
Licenses and Certifications: A license in one of the following is required:
Required Other Current unrestricted LPN/LVN state license
Required Intermediate Microsoft Excel Intermediate knowledge and skills of MS Office including Excel, Word and Outlook Express