Complex Case Manager

This job is no longer active. View similar jobs.

POST DATE 9/14/2016
END DATE 10/14/2016

Health Choice Preferred South Jordan, UT

South Jordan, UT
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
High School Diploma or GED


JOB SUMMARY: The Medical Case Manager manages and tracks all members who require a comprehensive approach to immediate and ongoing care of their complicated and/or catastrophic illnesses. This position also coordinates care for all members experiencing a care transition from one level of care back to their residence. The Medical Case Manager documents interactions with and on behalf of the member throughout service delivery including, but not limited to: care plans, progress notes, assessments, correspondence, and authorizations.

Job Responsibility:
Provide Case Management services to referred members:
*Act as a liaison to facilities, providers and/or members related to issues in case management and care services
*Identify member needs and address these needs to remove any barriers in achieving optimal behavioral health and medical care
*Educate members on the importance of good health and following up with the Primary Care Physician on a regular basis
*Review prior authorization/service requests with Medical Director for determination
*Complete member surveys, assessments and care plans
*Request and review medical records
*Provide and coordinate community resources and referrals
*Provide member education on disease processes
*Collaborate with the Interdisciplinary Team to incorporate best practices, assess outcomes and develop individualized care plans
*Develop and monitor the member s care plan goals for progress and outcomes
*Accurately document members case management plans, authorizations, assessment, and levels of care
*Attend case management team meetings, as scheduled
Identify members who had a recent transition of care and assist with follow up and discharge needs:
*Identify members through the daily inpatient census, who are a readmit within the last thirty (30) days and/or have specific disease conditions, such as, Diabetes, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Asthma
*Complete the Transition of Care survey with members
*Coordinate with all providers involved in the treatment of members identified as needing assistance with managing chronic medical conditions
*Assess member s medical, social, environmental and functional needs and address identified needs with the member s medical team and develop a comprehensive treatment plan
*Notify the member s Primary Care Physician of admission and discharge from any inpatient setting to facilitate coordination of care
*Monitor members for thirty (30) days post-discharge to ensure medical needs are met and to decrease readmission
*Monitor progress towards treatment goals
Monitor members identified through the High Utilization of ER Services Reports:
*Assist members in obtaining routine medical care through their assigned Primary Care Physician (PCP)
*Identify barriers in obtaining outpatient services outside of an ER
*Assist members and providers in developing a care plan which addresses member needs
*Educate members and providers on services available to address chronic disease, chronic illness management or other identified reasons for utilization of the ER
*Assist members with provider referrals, appointments and transportation, as needed
*Assist providers with the processing of Prior Authorization when needed, and remain a point of contact for both the providers and members
*Refer members to case management if the member is in need of ongoing case management services

Expected Outcomes:
*Health Choice staff serve as single point of contact
*Interdisciplinary team is engaged with the member to create care plans and discharge plans
*Members understand the difference between emergent and non-emergent services and where to access appropriate level of care
*Members utilize the ER in emergencies and PCP offices for routine needs
*Members understand role of case/disease management to assist them with their healthcare needs
*Authorizations are processed promptly so members obtain timely medical care
*Resources are identified to reduce barriers to receiving care in alternative setting than the ER
*A positive flow of communication with member and provider is maintained to promote goal achievement
*All member, provider and/or other agency concerns regarding complicated or catastrophic illnesses will be addressed
*Documentation is complete, accurate, following identified protocols and time frames
*Medical Review team makes accurate medical decisions on the requested service
*Transition of Care survey is completed for all members identified as in need of a Transition of Care program and follow up
*Needs are addressed in an alternative setting than inpatient care
*Coordination of care occurs with member s Primary Care Physician
*Member receives services to meet ongoing needs
*Gaps in care or services are addressed
*Members understand the difference between emergent and non-emergent services and where to access appropriate level of care
*Members understand role of case/disease management to assist them with their healthcare needs
*Authorizations are processed promptly so members obtain prompt medical care
*Resources are identified to reduce barriers to receiving care in alternative setting than the ER

Health Choice exists to improve the health and well-being of the individuals we
serve through our health plans, integrated delivery systems and managed care
solutions. We strive to recruit and retain only the finest health care
professionals with the highest levels of integrity, compassion and competency.
If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still
being valued for your individual strengths Health Choice is the place for you.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled
Professional Competencies (knowledge, skills, and abilities):

Knowledge of Medicare and Medicaid regulations and guidelines preferred
Knowledge of professional and community based resources helpful
Experience coordinating patient care
Knowledge of medical terminology

Computer experience necessary
Effective time management skills
Effective interpersonal and communication skills

Ability to use electronic medical record and claims systems
Ability to problem solve and work independently
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with members and providers
Ability to handle multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames
Ability to think analytically and make decisions independently
Handle multiple and changing priorities at a fast pace

High School Diploma or equivalent GED
Associate s degree or Bachelor s degree from an accredited Nursing School or
Bachelor s degree in Social Work or related field

At least two (2) years in a health care setting
HMO/Managed Care/ Medicare/Medicaid experience preferred

Certification and License:
Active, current, valid, unrestricted Arizona State Registered Nurse (RN) License, LPN, or Behavioral Health license, as applicable

Job: Business Services/Medical Records
Primary Location: Utah-South Jordan
Organization: Health Choice Preferred
Education Level: Associate's Degree/College Diploma
Employee Status: Full Time Benefit Eligible 36-40 hrs/wk
Work Schedule: Days