Supervises staff, ensures appropriate workload distribution and oversees day to day workflow processes. Ensures team is compliant with all model of care regulatory requirements, and produces optimal clinical, socio economic and resource outcomes. Ensures the case management process of assessing, planning, implementation, coordination, monitoring, and evaluating services and outcomes is pursued to maximize the health of the Member. Oversees the socio economic needs and services of selected member populations across the continuum of illness. Carries an assigned case workload and assumes a leadership role within the interdisciplinary team. Works directly with the member in the field, i.e., inpatient bedside, member's home, provider's office, hospitals, etc. to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the member.
DEPARTMENT: Health Services
REPORTS TO: Manager, Field Case Management/Field Service Coordination
- Supervises daily activities of the Field Service Coordination staff ensuring performance standards are met.
- Implements case management workflows and policies & procedures.
- Proactively monitors appropriate metrics to drive up efficiency.
- Perform audits of assessments, care plans and service notes to verify cases are properly established and that member coordination activities are occurring and appropriately documented.
- Carries an assigned case workload. Completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the members need for alternative services. Assess short-term and long-term needs and establish case management objectives.
- 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.
- 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.
- Conducts performance evaluation, hiring and termination decisions for associates in work group.
- Reviews time records, sets schedules and approves all vacation/time off requests for subordinate associates.
- Provides training and guidance to new and current Field Service Coordinators and/or Social Workers regarding policy & procedure, systemic tools, workload and care plan development.
- Answers all questions and assists peers and management with delegated tasks or projects.
- Takes the lead in preparing and submitting projects, reports or assignments as needed to meet department initiatives and/or objectives.
- Ensures phone or team coverage due to fluctuations in staffing levels.
- Ensures regulatory requirements and accreditation standards are applied to all activity and reporting.
- Plays active role in creating, applying and utilizing accepted policies and procedures.
- Attends company meetings in absence of manager.
- Ensures compliance with all state and federal regulations as well as Corporate guidelines in day-to-day activities.
- 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.
- Required a Bachelor's Degree in nursing required or equivalent work experience as an RN.
- Required 4 years of experience in case/behavioral management and/or clinical acute care experience
- Required 3 years of experience in managed care
- Required 1 year experience in leading/supervising others
- Required experience in care of the elderly is required in some geographic regions
- Required understands the business and financial aspect of case/behavioral management in a managed care setting
- Preferred prior utilization management experience preferred in some geographic regions
- Preferred home health, physicians office or public health experience a plus
Licenses and Certifications:
- Intermediate ability to communicate and make recommendations to upper management
- Intermediate demonstrated time management and priority setting skills
- Intermediate ability to multi-task
- Intermediate ability to lead/manage others
- Intermediate ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
- Intermediate demonstrated negotiation skills
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate demonstrated problem solving skills
- Intermediate knowledge of community, state and federal laws and resources and knowledge of community, state and federal laws and resources
- Intermediate ability to effectively present information and respond to questions from peers and management
- Intermediate ability to effectively present information and respond to questions from families, members, and providers
- Strong verbal and written communication skills including the ability to effectively present information and respond to questions from families, members, and providers as well as the ability to relate effectively to upper management
- Intermediate ability to work independently, handle multiple assignments, establish priorities, and demonstrate high level time management skills
- Intermediate previous experience working with treatment teams to meet the healthcare needs of participants
- Intermediate demonstrated written communication skills
- Intermediate ability to lead and manage others in a metric driven environment
- Intermediate ability to implement process improvements
- Intermediate strong clinical knowledge of broad range of medical practice specialties
- Intermediate knowledge of healthcare delivery
A license in one of the following is required:
- Required Licensed Registered Nurse (RN) or LCSW licensure
- Preferred Certified Case Manager (CCM)
- Required intermediate Microsoft Word, Outlook, and Excel
- Required Intermediate Microsoft Outlook 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)