Medical Case Manager - GHP

Job ID: J118222
Company: Gateway Health Plan
Location: Home, DE, United States
Facility: Work From Home
Full/Part Time: Full time
Job Type: Regular
Posted at:

Share:

Description

I. GENERAL OVERVIEW:  

Assure that members with complex medical and/or psychosocial needs have access to high quality, cost-effective health care. Assist in the holistic assessment, planning, arranging, coordinating, monitoring, evaluation of outcomes and activities necessary to facilitate member access to healthcare services. Advocate for the most appropriate care plan using sound clinical judgment; accurate planning, and collaboration with internal and/or external customers and contacts. Follow 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. Facilitation and/or participation in interdisciplinary and/or interagency meetings when necessary to facilitate coordination of services/resources for members.

II. ESSENTIAL RESPONSIBILITIES: 

1. Communicate effectively. This position displays effective communication skills while performing the following functions:

  • Customer telephonic interviewing and communication with external contacts.
  • Interaction with Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.

2. Knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States

  • The Medical Case Manager will be expected to 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.
  • The Medical Case Manger will collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.
  • The Medical Case manager will 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.

3. Problem Solving/Latitude

  • The Medical Case Manager will be expected to work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member.
  • The Medical Case Manager is expected to 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.
  • The Medical Case Manager will have support from the department’s Management Team and Case Management Specialists.

4. Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services. 

  •  The Medical Case Manager will 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.
  • Communication and collaboration with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
  • The Medical case manager will maintain a working knowledge of available community resources available to assist members.  The Medical Case manager will coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.

5. Work within a Team Environment

  • Attend and participate required meetings, including staff meetings, internal Rounds, and other in-services in order to enhance professional knowledge and competency for overall management of members.
  • Participation in departmental and/or organizational work and quality initiative teams.
  •  Case collaboration 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.

6. Professional Development

  • 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.

7. Other duties as assigned or requested.

III. QUALIFICATIONS:

Education, Licenses/Certifications, and Experience

Minimum

  • 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.

Preferred

  • Experience working with high risk pregnant women OR experience working with chronic condition adult populations OR experience with pediatrics.
  • Three to five 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

IV. SCOPE OF RESPONSIBILITY:

Does this role supervise/manage other employees?     No    

If yes, indicate the number of direct reports: 

V. WORK ENVIRONMENT:

Is Travel Required?

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.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

Share:

Interested in working at the Highmark Health enterprise?
Take the first step by joining our Talent Network today!

Join Our Talent Network

Similar Jobs

Case Manager

Home, PA, United States
Clinical Services

Stationary Engineer

Natrona Heights, PA, United States
Facilities Management & Real Estate

Multi Test Tech- Part-time

Jefferson Hills, PA, United States
Tech

TECH PHARMACY

Jefferson Hills, PA, United States
Pharmacy

Nursing Assistant I-12C - Telemetry-Full Time

Pittsburgh, PA, United States
Patient Support

Food Service Associate - Part Time

Jefferson Hills, PA, United States
Food/Nutrition

Food Services Associate - Allegheny General Hospital - Part Time

Pittsburgh, PA, United States
Food/Nutrition

Manager, Disease Management

Wilmington, DE, United States
Clinical Services

Nursing Assistant - PCU E7 - Full-Time

Pittsburgh, PA, United States
Patient Support

Executive Administrative Assistant

Wilmington, DE, United States
Administrative Services

Staffing Clerk- Full Time

Jefferson Hills, PA, United States
Patient Support

Sr Plumber

Pittsburgh, PA, United States
Facilities Management & Real Estate

Patient Care Associate - ICU/CCU - Full-Time

Natrona Heights, PA, United States
Patient Support

Enrollment & Billing Representative

Harrisburg, PA, United States
Customer Service

Education and Developmental Specialist

Pittsburgh, PA, United States
Nursing

Patient Placement Associate-Full Time

Jefferson Hills, PA, United States
Patient Support

Craft Assistant

Pittsburgh, PA, United States
Facilities Management & Real Estate

Cardiac Transport Monitor Tech- Float Pool- Full Time

Pittsburgh, PA, United States
Tech

Patient Host or Hostess - Allegheny General Hospital - Full Time

Pittsburgh, PA, United States
Food/Nutrition

Complex Case Manager

Home, DE, United States
Clinical Services

Registered Nurse- Weekend- Oncology

Monroeville, PA, United States
Nursing

Intern-- Human Resources

Pittsburgh, PA, United States
Other

Patient Host or Hostess - Allegheny General Hospital - Casual

Pittsburgh, PA, United States
Food/Nutrition

Patient Host or Hostess - Allegheny General Hospital - Casual

Pittsburgh, PA, United States
Food/Nutrition