Medical Case Manager
5 - 7 years experience • Business Services
This position is accountable for promoting interdependent collaboration with the member, physician/primary care manager, family and other members of the health care or case management team. To accomplish this collaboration, the case manager will assess, implement, monitor, and evaluate available resources in an effort to promote quality, cost effective outcomes while meeting the individual’s health needs. The case manager identifies appropriate providers and facilities in an effort to improve or maintain the social, emotional, functional and physical health status of the client, as well as enhance the coping skills of the family or other caregiver.
Job Duties & Responsibilities
Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.
The case manager will perform the six essential activities of case management:
- Assessment – The case manager will collect information about a person’s situation and functioning to identify individual needs in order to identify members risk for high cost medical care and develop an appropriate case management plan that will address those needs.
- Planning – The case manager will determine specific objectives, goals, and actions as identified through the assessment process. The plan should be action oriented and time specific
- Implementation – The case manager will execute specific intervention that will lead to accomplishing the goals established in the case management plan
- Coordination – The case manager will organize, integrate, and modify the resources necessary to accomplish the goals established in the case management plan
- Monitoring – The case manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the case management plan
- Evaluation – At appropriate and repeated intervals, the case manager will determine the plan’s effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the case management plan in its entirety or in any of its component parts
Case Management Functions
- 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 case 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.
- 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, and payer representatives.
- 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 to care, providers and/or services to promote better outcomes.
- Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provided when appropriate.
- Report quantifiable impact, quality of care and/or quality of life improvements.
- Participate in Inter-reviewer reliability to identify quality of care issues and criteria inconsistencies.
- Maintain requirements of documentation according to case type 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.
- 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.
- Must have or be able to be licensed in multiple states if required
- Minimum of 5 years health care experience with at least three (3) years of clinical experience,
- Prefer two (2) years experience in Utilization Management, Case Management or Managed Care.
- Certified Case Manager (CCM®) credential preferred; required to take examination when eligible. Case Managers must obtain a CCM certification within 2 years of hire as a case manager or they will no longer be able to perform case management functions
- Excellent oral and written communication skills, with problem-solving abilities.
- Basic PC computer skills required with emphasis on Microsoft Office applications preferred
- Various immunizations and/or associated medical tests may be required for this position.
Population Health Case Management
Position may be assigned to condition-specific cases such as Disease Management (Chronic Care and Complex Conditions), Maternity Management, or Transplant Management.
Job Duties & Responsibilities
- Responsible for carrying out key functions related to the success of the case management program to include acting as key liaison between the practice and the health plan
- Performs functions, as necessary, for members identified as having Comorbid health conditions that meet eligibility requirements for the program
- Assesses, identifies, educates, collaborates, prioritizes needs, and builds rapport and trust through education
- Conducts any needed concurrent reviews to determine appropriate level of care and length of stay using established criteria
- Provides on-site services as necessary
- Interacts with other departments as necessary to ensure smooth transfer of member information across the continuum of care
- Seeks advice of the Medical Director when appropriate
- Proficiency with Motivational Interviewing and/or other behavioral change techniques
- Ability to build rapport and engage members in effective dialogue related to their treatment plan
- Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions
- Exceptional level of critical thinking, analytical and creative problem solving skills required.
- Exceptional level of independence, organization, and interpersonal skills required.
- Proficient with team-building processes and participation in cross-functional teams
- Adherence to the Corporate Tuberculosis Testing Policy 025.HR.078 and Tuberculosis Procedure 025.HR.078.A (if applicable)
- Must have or be able to be licensed in multiple states if required.