Responsibilities
Provide comprehensive telephonic case management to targeted population who are identified with chronic diseases, as well as medically complex members referred for outreach.
Develop a tailored plan of care that supports the needs of the members, influences adherence to treatment, assist with discharge planning as needed and care coordination to ensure optimal outcomes
- Apply nationally recognized clinical evidence-based guidelines and best practices approach to identify and address gaps in care
- Communicate effectively with members, physicians, and providers; facilitate, advocate, and educate on the disease process;
be a liaison and provide referrals to other departments and programs as needed
- Use of information technology; navigate within care management application and document management systems and maintain accurate documentation of case management assessment, planning, goals and interventions.
- Act as a Subject Matter Expert based on particular disease management areas of expertise : facilitate ongoing staff training, provide information regarding medications updates and continued education
- Interpret reports, understand trends and target specific high risk population, provide recommendations, generate outcomes.
- Promote active members involvement regarding their health care management and ability in navigating health care delivery systems in order to preserve benefit resources
- Authorize vendor services using clinically proven criteria to make consistent care decisions
- Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services
- Responsible for abiding by and supporting the care management programs in order to ensure quality and efficient clinical operations
- Use industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach
- Participation in Fund wide clinical events and Health Fairs
- Perform additional duties and projects as assigned by management
Qualifications
- Valid New York State Registered Nurse (RN) required
- Minimum three (3) years Medical / Surgical experience plus a minimum of two (2) years Case Management / Disease Management experience required
- BSN and Certification in Case Management a plus
- Knowledge of HEDIS, NCQA, QARR a plus
- Strong knowledge of Clinical evidence-based guidelines, industry standard Utilization Management criteria (Milliman Care Guidelines), Medicare and coverage guidelines, health claims processing, medical coding
- Excellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capability
- Computer and organizational skills required, ability to manage competing priorities, multi-task with results oriented outcomes and work in a fast paced environment.
Intermediate skills of Microsoft Office systems preferred.
7 days ago