The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individuals benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.
Fundamental Components include but are not limited:
- Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.
- Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits
- Using holistic approach consults with supervisors, Medical Directors and/or others to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes - Identifies and escalates quality of care issues through established channels
-Utilizes negotiation skills to secure appropriate options and services necessary to meet the members benefits and/or healthcare needs.
- Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures
- RN with current unrestricted state licensure is required
- 3-5 years clinical practice experience is required
- Managed care industry experience preferred
- Case Management experience is preferred
- Case Management Certification "CCM" preferred
- Bi-lingual capabilities a plus, especially Spanish
- Excellent verbal and written communication skills are required
- Proficiency in typing and use of computer applications is required
The minimum level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is required
Functional - Medical Management/Medical Management - Case Management/1-3 Years
Functional - Medical Management/Medical Management - Discharge planning/1-3 Years
Functional - Medical Management//
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
Benefits Management/Understanding Clinical Impacts/FOUNDATION
Leadership/Collaborating for Results/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED