This job works directly with providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted related to quality and care costs. The incumbent's responsibilities could include working in a physician’s office, visiting physician practices on a routine basis, working within a hospital setting and/or assessing and coordinating member’s care within the member’s home. Helps members to coordinate care and navigate the healthcare system by recommending and/or implementing interventions related to the improvement of medical care and costs.
- Conduct member-facing clinical assessments that address the health and wellness needs of members using a broad set of clinical and motivational interviewing skills with the goal of impacting members’ self-management skills and positive behavior changes which will ultimately positively impact member satisfaction and care costs.
- Serve as a subject matter expert to both internal and external sources (e.g. providers, regulatory agencies, UM and policy.) to provide education, consultation and training when indicated.
- Serve as a resource to guide, mentor and counsel others in regard to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources.
- Collaborate, coordinate and communicate with the member’s treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention.
- Develop/implement case or condition-specific plans of care and/or intervention plan, as needed, that can become a part of the member’s EMR or medical record to establish short and long-term goals.
- Establish a plan for regular contact ( face-to-face as often as possible) with each member and/or provider to monitor progress toward goals, provide additional education and evaluate the need for modification or change in the plan of care.
- Proactively incorporate lifestyle improvement opportunities and preventive care into member interactions and coaching.
- Collaborate with the appropriate individuals to offer solutions to refine and improve existing practices or participates in developing performance improvement processes that will enhance member outcomes and operational performance/excellence as well support all strategic initiatives including Health Care Reform and STARS initiatives.
- Work with providers related to performance measures and activities to educate and influence the behavior of members and providers.
- Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
- Other duties as assigned or requested.
- Current PA RN license and/or additional states as required or current Social Work license
- 4 years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience
- Clearances as required by specific practice or hospital, as applicable
- Certification in Case Management (CCM)
- 5 years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience
- Ability to work in a virtual environment (e.g., provider offices, facilities and/or member’s homes); accomplishing and coordinating work remotely
- Proficiency in MS Excel and enhanced data and statistical analysis skills
- Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
- Broad knowledge of the health care delivery system including an understanding of health care costs drivers
- Excellent verbal and written communication skills including individual and/or group education/training
- Experience working with the healthcare needs of diverse populations and understanding the importance of cultural competency in addressing targeted populations.
- Self-directed; self-starter; ability to work successfully with indirect supervision and moderate autonomy
- Excellent organizational, time management and project management skills
- Ability to work in a fast paced, high visibility, high performing team environment that requires flexibility
- Ability to travel locally and work flexible hours in a practice or facility-based settings
- Ability to communicate effectively in more than one language, preferred
- Experience working directly with physicians in provider practice settings, members in a home environment or hospital discharge processes.
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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