Coordinates the care and service 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 with the Supervisor / Manager of Case Management to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the Member.
Essential Functions:
* In conjunction with the
PCP and member, completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the member’s need for alternative services. Assess short-term and long-term needs and establish case management objectives.
* Manages 80 to 120 active cases based on case intensity and acuity.
* 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.
* Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
* Maintains accurate records of case management activities in the
EMMA System using clinical guidelines.
* Coordinates community resources with emphasis on medical, behavioral and social services. Applies case management standards and maintains
HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
* Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
* Participates in monthly chart audits
* Performs special projects as assigned.
job Requirements
Education/Experience:
1. Current State RN licensure.
CCM preferred
2. Required: 3-5 years clinical experience, Critical Care, Home Health, Public Health, etc.
3. 1-3 years current case management required
4. Bilingual skills a plus
5. Assists in evaluating process improvements
6. Ability to work independently, handle multiple assignments and prioritize workload
7. Demonstrates high level time management and priority setting
8. Communicates effectively in person and by phone
9. Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position.
10. Ability to create, review and interpret treatment plans
11. Demonstrates negotiation skills
Computer Skills:
* Intermediate knowledge and skills of MS Office including Excel, Word and Outlook Express
* Knowledge of Sidewinder and Diamond system sufficient to perform review and data entry preferred; Ability to learn company approved software including
CRMS database,
EMMA and Diamond computer system and other industry software in order to perform job duties
Case Manager