This position supports MissouriCare, which is a member of the WellCare group of companies.
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.
Reports to: Manager, Case Management
Location: Columbia, MO
Dept: Field Health Services
- 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.
- A Bachelor's Degree in Nursing or Health Administration and Licensed Registered Nurse or A Master's Degree in Social Work and Licensed Clinical Social Worker
- 4 case/behavioral management and/or clinical acute care experience.
- Home health, physicians office or public health experience a plus.
- 3 years managed care experience.
- 1 years leading/mentoring others.
- Understands the business and financial aspect of case/behavioral management in a managed care setting.
- Prior utilization management experience preferred in some geographic regions. Experience in care of the elderly is required in some geographic regions.
- Current State RN or LCSW licensure.
- Maintain required contact hours to fulfill regulatory requirements.
- CCM preferred.
Special Skills (e.g. 2nd language):
- Strong clinical knowledge of broad range of medical practice specialties
- Demonstrates effective communication methods to assist in training and to relate effectively to upper management
- Assists in evaluating process improvements
- Demonstrates high level time management and priority setting
- Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position
- Ability to lead and manage others in a metric driven environment
- Ability to create, review and interpret treatment plans
- Demonstrated negotiation skills
- Demonstrated ability in problem solving and communication
- Previous experience working with treatment teams to meet the healthcare needs of participants
- Knowledge of community, state and federal laws and resources
- Strong oral 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.
- Ability to work independently, handle multiple assignments, establish priorities, and demonstrate high level time management skills.
- Proficient in Microsoft Office including Outlook, Word and Excel.
- 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.