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Works with Care Coordination MVP Team members to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the Member. Coordinates, monitors and ensures that appropriate and timely primary, acute and long-term care services are provided to members across the continuum of care. Promotes effective healthcare utilization, monitors health care resources and assumes a leadership role within the Interdisciplinary Care Team (ICT) to achieve optimal clinical and resource outcomes for member. Coordinates the care and services of selected member populations 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 directly with the member in the field, i.e., inpatient bedside, member's home, provider's office, hospitals, etc. while collaborating with management to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the member.
Evaluates members for case management services and determines appropriate level of care coordination/ management services for member.
Completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the members need for alternative services.
Acts as a primary case manager for members identified as Complex as defined by Case Management Program Description.
Develops and monitors members plan of care, to include progress toward meeting established goals and self-management activities.
Interacts continuously with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status. Assess the options for care including use of benefits and community resources to update the care plan.
Supervises and/or acts as a resource for non-clinical staff (i.e., Service Coordinators and Field Social Workers).
Act as liaison and member advocate between the member/family, physician and facilities/agencies.
Maintains accurate records of case management activities in the Enterprise Medical Management Automation (EMMA) System using clinical guidelines.
Coordinates community resources, with emphasis on medical, behavioral, and social services. Applies case management standards, maintains HIPAA standards and confidentiality of protected health information and reports critical incidents and information regarding quality of care issues.
Ensures compliance with all state and federal regulations as well as Corporate guidelines in day-to-day activities.
Meets with clients in their homes, work-sites, physician's or hospital to provide management of services.
Adapts to changes in policies, procedures, new techniques and additional responsibilities.
Participates with other Case Managers and Medical Directors in regular or special meetings such as Clinical rounds.
Perform other duties as assigned.
Travel to inpatient bedside, member's home, provider's office, hospitals, etc required with dependable car. May spend up to 70% of time traveling with exposure to inclement weather and normal road hazards. May require climbing multiple flights of stairs to a member's home, provider's office, etc.
A Bachelor's Degree in Health Services or Nursing or equivalent work experience required.
2 years of experience in clinical acute care required.
1 year of experience in current case management preferred.
Managed care experience preferred.
Prior utilization management experience preferred in some geographic regions preferred.
Experience in care of the elderly is required in some geographic regions preferred.
Experience in home health, physicians office or public health preferred.
Intermediate - Ability to multi-task
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.
Intermediate - Ability to implement process improvements.
Intermediate - Ability to effectively present information and respond to questions from families, members, and providers.
Intermediate - Ability to understands the business and financial aspect of case mgmt in a managed care setting.
Intermediate - Knowledge of healthcare delivery.
Intermediate - Knowledge of community, state and federal laws and resources.
Intermediate - Demonstrated written communication skills.
Intermediate - Demonstrated customer service skills.
Licenses and Certifications:
Licensed Registered Nurse (RN) required.
Requirement to maintain required contact hours to fulfill regulatory requirements.
Certified Case Manager (CCM) preferred.
Intermediate proficiency in Microsoft Outlook, Word and Excel required.
Proficiency in Microsoft PowerPoint and Access preferred.
Knowledge of, or the ability to learn company healthcare management systems in order to perform job duties required.