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Provides telephonic-based contact with members who have been pre-identified as having chronic disease states. Completes clinical assessments on each member to determine the educational health needs based on their disease process, and to monitor the level of adherence. Provides self-management support including care integration for the members enrolled into the disease management program. Assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes. Assesses, plans, implements, coordinates, monitors and evaluates care plans, services and outcomes to maximize the health of members.
Provides telephonic member assessment as the result of inbound and outbound member phone calls.
Completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the members need for alternative services. Assesses short-term and long-term needs and establishes disease management objectives.
Educate and assist members in understanding their disease process in an effort to increase self-management maximize optimal health
Emphasizes the importance of health education and teaches member behavior modification techniques
Utilize evidenced based guidelines to educate members on their specific disease process
Identify members educational needs and mail appropriate educational material to each member
Monitor members per results of the clinical assessment on a continual basis
Promote and encourage members regarding adherence to their care plan and treatment as set by the caregiver Provide referrals as appropriate.
Communicate with providers regarding member needs.
Collaborates with Case Managers on cases to review care plans and make changes if necessary.
Act as liaison and member advocate between the member and their family, physician and facilities/agencies.
Manages 100 active cases based on case intensity and acuity.
Interacts continuously with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status, Assesses options for care including use of benefits and community resources to update the care plan as needed.
Maintains accurate record of disease management activities in the Enterprise Medical Management Automation (EMMA) System using clinical guidelines.
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.
Coordinates community resources with emphasis on the development of natural support system. Coordinates benefits, regulations, laws and public entitlement programs for members.
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred A Bachelor's Degree in health administration, nursing or related field
Required 2 years of experience in a clinical acute care position(s) in varied health care settings with an expertise in cardiovascular disease, diabetes, asthma, pediatrics etc
Required 1 year of experience in disease management
Preferred Other Managed care experience
Intermediate Ability to work independently
Intermediate Ability to drive multiple projects
Intermediate Ability to multi-task
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Ability to create, review and interpret treatment plans
Intermediate Demonstrated time management and priority setting skills
Intermediate Ability to work in a fast paced environment with changing priorities
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
Licenses and Certifications: A license in one of the following is required:
Required Licensed Registered Nurse (RN)
Required Beginner Microsoft Excel
Required Beginner Microsoft Word
Required Beginner Healthcare Management Systems (Generic)