Job Duties & Responsibilities
Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions. (Applies to position specific positions as well)
The care coordinator will perform the following essential activities of care coordination:
- Assessment – The care coordinator will assess information about a members’ medical care needs, social situation and functioning to identify individual needs in order to identify members medical needs and develop a plan of care that will address those needs.
- Planning – The care coordinator will involve the enrollee and other significant parties in the determination of specific objectives, goals, and actions as identified through the assessment process. The care coordinator will use the information to develop a plan specific to the enrollee’s medical needs.
- Implementation – The care coordinator will facilitate and execute specific interventions that will lead to accomplishing the goals established in the plan of care to ensure the member’s health, safety, and welfare.
- Coordination – The care coordinator will organize, integrate, and modify the resources necessary to accomplish the goals established in the plan of care.
- Monitoring – The care coordinator will gather sufficient information from all relevant sources in order to determine the effectiveness of the plan of care.
- Evaluation – At appropriate intervals, the care coordinator will determine the plan of care’s effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the plan of care in its entirety or in any of its component parts.
- Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
- Minimum of 5 years healthcare w/ 3 years clinical experience required.
- 2 years experience in Utilization Management, Case Management or Managed Care.
- Must be PC literate with extensive knowledge of Windows and Microsoft Office.
- Must be able to pass Windows navigation test.
- FACETS and Care Advance experience preferred.
- Exceptional skills of independence, organization, communication, problem-solving, professional interaction, and human relation skills, as well as analytical skills and problem solving ability
- Ability to work within specified timeframe requirements.
- Valid Driver’s License
- TB Skin Test (applies to coordinators that work in the field)
- Certification as a Case Manager (CCM) preferred; required to take examination when eligible.
- Milliman’s Certification Preferred.
- Position requires 24 months in role before eligible to post for other internal positions
Position Specific Requirements for DSNP
Duties & Responsibilities
- Promotes an Interdisciplinary Care Team (ICT) with the member, physician/primary care manager, family, and other members of the health care or case management team to conduct care management activities.
- Develops and implements an individualized plan of care (POC), updates POC as health status changes occur, and seeks updated POC approval from ICT participants.
- Conduct a thorough and objective evaluation of the client’s current status including physical, psychosocial, environmental, financial, and health status expectation.
- As a client advocate, seek authorization for care management from the recipient of services (or designee).
- Assess resource utilization and cost management; the diagnosis, past and present treatment; prognosis, goals (short- and long-term).
- Identify opportunities for intervention.
- Assess, coordinate, and facilitate discharge planning or transition to the appropriate level of care.
- Set goals and time frames for goals appropriate to individual.
- Arrange, negotiate fees for, and monitor appropriate cases and services for the client.
- Maintain communication and collaborate with patient, family, physicians and health team members, ICT participants and payer representatives.
- Facilitate ICT meetings/discussions.
- Compare the client’s disease course to established pathways to determine variances and then intervene as indicated.
- Routinely assess client’s status and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
- Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provider.
- Report quantifiable impact, quality of care and/or quality of life improvements as measured against the case management goals.
- Maintain requirements of documentation and caseload as reflected in audits to meet compliance with quality standards.
- Conduct case screenings using applicable tools to determine appropriate levels needed to meet member needs.
- Adhere to and apply CMS guidelines and the Bureau of TennCare guidelines regarding the Dual Eligible Special Needs Program (DSNP) including the Model of Care (MOC) and when performing care management functions.