July 9, 2019
The Care Manager will support the Population Health Management efforts of select clients of The Benefit Company. Such will include acting as patient/family advocate in coordinating and accessing medical necessity health care services within the benefit plan for members that have chronic, complex and catastrophic conditions. The care manager shall work in a collaborative means to promote quality and efficient care, as well as cost-effective outcomes that will enhance the physical, psychosocial, and vocational health of the plan participants. The Care Manager will also be involved in coordinating Disease Management programs, and the ideal candidate will have an entrepreneurial mindset to support the incubation of our Employer Based Case Management efforts.
Essential Job Functions
- Interest in building an innovative employer based case management practice.
- Maintenance of Confidentiality/HIPAA Standards
- Adheres to the applicable URAC Standards, Principals and Procedures
- Adheres to Policies and Procedures, Company Principles
- Ability to read and interpret Summary Plan Documents and other related resources relating to service requests
- Knowledge and correct application of data collection techniques and tools
- Knowledge and correct application/participation of UM, QA, and complaints/grievances workflow; disaster plan; consumer and employee safety
- Identifies cases for individual management—from data mining, precertification process, Plan referral or information collected from patients, providers, and caregivers. Conducts thorough assessment, develops and implements a care management plan, including goals, as appropriate
- Implements the care plan and manages case to conclusion, while maintaining contact with all individuals involved. Evaluates and ensures that the goals identified in the care management plan are met on a regular basis. Makes modifications as appropriate to the care management plan based upon the reassessment of the member..
- Always responsible and retains accountability for the case management plan and process
- Uses established evidenced based guidelines/criteria to evaluate treatment plans and goals based on information obtained from attending physician and/or other providers. Refers cases that do not meet evidenced based guidelines/criteria to appropriate clinical advisor
- Refer patients to appropriate resources to allow for positive outcomes relating to their disease state
- Educate and assist patients in understanding their condition to improve self management and maximize their health status potential
- Identifies potential cost savings within a health plan’s coverage. Acts upon cost savings in instances when services would not be sacrificed by doing so
- Obtains/maintains knowledge of Federal, State, and Local regulations, funding, and community resources available to patients and their families
- Performs all job duties and responsibilities within the scope of State & Federal laws, licensure/certification as well as within the ethics described in the CMSA’s Standards of Practice
- Collaborates with other departments to promote coordination and communication within the Company regarding integration of administrative activities, quality improvement, and clinical operations
- Conducts research as appropriate, to obtain/maintain knowledge of cultural differences including socioeconomic factors, cultural traditions, and spiritual beliefs.
- Responsible for documenting completely and appropriately information obtained from telephonic, fax or emailed requests within the care management system
- Ability to work collaboratively with other members of the team
- Responsible for providing all aspects of excellent internal and external customer service and development
- Maintains essential license and/or job-related educational requirements
- Minimum of 3 years nursing experience in an acute care or relevant setting.
- Registered Nurse licensure with active and unrestricted license to practice in the state of primary residence or multistate licensure if primary residence is a compact state.
- Additional state licensures preferred but not required
- Certification in appropriate field of expertise (ie: Certified Case Manager, Chronic Care Professional), preferred but required within 4 years of hire.
- Ability to attend to numerous details under the stress of maintaining courteous, accurate and timely relations with a variety of individuals
- Ability to work independently, with minimal supervision; Willingness to coordinate and design processes and coordinate infrastructure/systems deployment.
- Ability to comprehend the consequences of various problem situations and to refer such problems to the appropriate individual (or supervisor) for decision-making
If you share our passion for making a positive difference, we invite you to contact us today with your resume and cover letter at email@example.com