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 member’s 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.
- An Associate degreed Registered Nurse or Bachelor's Degree/BSN is required.
- 2-4 years' clinical acute care experience.
- Home health, physician’s office or public health experiences a plus.
- At least 1-3 years' current case management experience preferred
- Managed care experience preferred.
- Understands the business and financial aspect of case mgmt. 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 licensure, no restrictions.
- Maintain required contact hours to fulfill regulatory requirements.
- CCM strongly preferred
Special Skills (e.g. 2nd language):
- Bilingual skills a plus
- Assists in evaluating process improvements
- Ability to work independently, handle multiple assignments and prioritize workload
- Demonstrates high level time management and priority setting
- Communicates effectively in person and by phone
- Ability to work independently in various environments
- Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position
- Ability to create, review and interpret treatment plans
- Understands the business and financial aspect of case mgmt in a managed care setting.
- Proficient in Microsoft Office including Excel, Word, PowerPoint, Access and Outlook Express.
- 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.