This job assures that members with complex medical and/or psychosocial needs have access to high quality, cost-effective health care. Assists in the holistic assessment, planning, arranging, coordinating, monitoring, evaluation of outcomes and activities necessary to facilitate member access to healthcare services. Advocates for the most appropriate care plan using sound clinical judgment; accurate planning, and collaboration with internal and/or external customers and contacts. Follows established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care. Facilitates and/or participates in interdisciplinary and/or interagency meetings, when necessary, to facilitate coordination of services/resources for members.
- Communicate effectively while performing customer telephonic interviewing and communication with external contacts.
- Communicate effectively while interacting with Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
- Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States
- Educate members in order to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.
- Collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.
- Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs.
- Work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member.
- Develop an individualized plan of care designed to meet the specific needs of each member.
- Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated.
- Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services.
- Be knowledgeable of and consider benefit design and cost benefit analysis when planning a course of intervention in order to develop a realistic plan of care.
- Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
- Maintain a working knowledge of available community resources available to assist members.
- Coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.
- Work within a Team Environment.
- Attend and participate in required meetings, including staff meetings, internal Rounds, and other in-services in order to enhance professional knowledge and competency for overall management of members.
- Participate in departmental and/or organizational work and quality initiative teams.
- Case collaborate with peers, Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
- Participate in interagency and/or interdisciplinary team meetings when necessary to facilitate coordination of member care and resources.
- Foster effective work relationships through conflict resolution and constructive feedback skills.
- Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.
- Educate health team colleagues of the role and responsibility of Case Management and the unique needs of the populations served in order to foster constructive and collaborative solutions to meet member needs.
- Other duties as assigned or requested.
- Bachelor’s degree in nursing or RN certification or Master’s degree in Social Work and 3 years experience in Acute or Managed Care/ experience with Medicaid or Medicare populations. OR
- Bachelor’s degree in Social Work with five years experience in Acute or Managed Care/ experience with Medicaid or Medicare populations
- Experience working with high risk pregnant women OR experience working with chronic condition adult populations OR experience with pediatrics
- 3-5 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
- Bilingual English/Spanish language skills.
- Case Management Certification
- Professionally Licensed Social Worker or Nurse
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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