Job ID: J125495
Company: Gateway Health Plan
Location: Home, WV, United States
Facility: Work From Home
Full/Part Time: Full time
Job Type: Regular
Posted at: Jul 12, 2018
Responsible for providing case management services, both telephonic and through face to face visits, to members identified as having complex medical and/or psychosocial needs. Assist in the holistic assessment, planning, arranging, coordinating, monitoring, and evaluation of outcomes and activities necessary to facilitate member access to high quality and cost effective 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. Participation in interdisciplinary meetings when necessary to facilitate coordination of services/resources for members.
Essential Responsibilities/Job Functions:
Communicate effectively by telephone and face to face interactions; with internal and external sources as needed, for collection of medical information and care plan development.
Knowledge of medical terminology, medical diagnostic categories, and disease states.
Proficient in the use of computer based technology in order to perform job duties in a remote setting and exhibits a strong working knowledge of Microsoft office products.
Ability to work independently using sound clinical judgment to identify, define, and resolve a myriad of problem types experienced by the member but can involve collaboration from a team of case managers and the management team for support as needed.
Develop an individualized plan of care designed to meet the specific needs of each member.
Education to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.
Collaboration with primary care physicians, medical specialists, home health and other ancillary healthcare providers with the goal being to coordinate member care.
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.
Establish and maintain a working knowledge of available community resources available to assist members as well as coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.
Communication and collaboration with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
Remain 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.
Attend and participate in required meetings and educational in-services to enhance professional knowledge and competency for overall management of members.
Foster effective work relationships through conflict resolution and constructive feedback skills.
Participate in departmental and/or organizational work groups and quality initiative teams.
Other duties as assigned or requested.
Ability to work from home with high speed internet access
Potential for travel (approximately 25% of the time)
Licensed Registered Nurse or Social Worker in the State of WV with active, unrestricted license
3-5 years of experience in Acute or Managed Care setting
Prior case management experience
Experience working with chronic conditions/managed care programs/Medicaid population
Bachelor’s Degree in Nursing or Masters in Social Work
Case Management Certification (CCM)
Unusual Working Conditions
This job requires the ability to work independently and as a team member. Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or weekends.
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