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
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