Provides support for field case management program. Coordinates services and performs administrative functions. Assists in completing activities related to various cross functional projects in support of departmental goals. Conducts telephonic and mail outreach to members who are identified as requiring outreach services in support of clinical quality initiatives and regulatory/contractual requirements. Provides assistance to member to close identified health care gaps. Screen members to identify needs and enroll into Field Case Management program as needed.
Reports To: Manager, Field Care Management
Department: Health Services
Position Location: Columbia, SC.
- Assigned a caseload for outreach and engagement into field case management program
- Monitors and follows up on members seen in the Emergency Department and discharged on the same day to ensure member has established an appointment with primary provider.
- Conducts research, including reviewing medical records, service authorization and case notes to determine member needs before outreach.
- Conducts telephonic and mail outreach to members, providers and community organizations to support Case Management and/or Quality Improvement, regulatory and contractual metrics and requirements.
- Maintains accurate records of activities in the Enterprise Medical Management Application (EMMA) and other proprietary IT applications using clinical guidelines.
- Maintains HIPAA standards and ensures confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
- Serves as a liaison in corresponding and communicating with providers, vendors and WellCare contacts and/or members representative’s.
- Responds to phones as assigned or team coverage as directed by Supervisor.
- Provides administrative support to clinical and behavioral staff as needed.
- Interacts with other departments including Claims, Intake, Enrollment and Member Services to resolve member and provider issues.
- Assists, completes and submits special projects, reports or assignments to meet department needs and objectives.
- Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
- Performs other duties as assigned.
- If position is not primarily telephonic, will travel to inpatient bedside, member’s home, provider’s office, hospitals, etc as required with dependable car. May spend up to 70% of time traveling with exposure to inclement weather and normal road hazards.
- Support the lead database by providing feedback with strategies to improve the quality of referrals to ensure the appropriate members are outreached.
- Required A High School or GED
- Required 2 years of experience in medical office or other relevant health care experience
- Preferred Other Experience in working with special populations, such as HIV/AIDS, developmental disabilities, medically fragile children, geriatrics, persons with neurotrauma, and younger adults with physical disabilities
- Preferred Other Managed care experience
Licenses and Certifications:
- Intermediate Ability to work independently
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Knowledge of healthcare delivery
- Intermediate Ability to represent the company with external constituents
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Knowledge of community, state and federal laws and resources
- Intermediate Demonstrated customer service skills
A license in one of the following is required:
- Required Intermediate Microsoft Outlook Proficient in Microsoft Office including Excel, Word and Outlook
- Required Intermediate Microsoft Excel Knowledge of data entry,documentation and report generation in any clinical system a plus
- Required Intermediate Microsoft Word Knowledge of or the ability to learn company approved software such as CRMS, Peradigm, InterQual, Sidewinder and other software in order to perform job duties
- Required Intermediate Healthcare Management Systems (Generic)
- Preferred Intermediate Other Knowledge of data entry, documentation and report generation in any clinical system