Case Manager

Summary: The practice of case management is a process that manages client wellness and autonomy through advocacy, communication, education, and the identification and facilitation of services.1 Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs. It uses communication and available resources to promote quality, cost-effective outcomes.2

The Nurse Case Manager role and responsibilities span a culturally diverse population from neonatal to geriatric and may vary depending upon project assignment; however, regardless of payer or line of business, the case manager applies the same core practices of case management tailored to each member’s unique disease, condition, and cultural values. The corporation throughout its multiple lines of business as an MSO, has various projects where case management services are needed that include, but is not limited to Medicare FFS, HMO, PFFS, Medicaid, Dual Eligibles and QMBs, Medicare Advantage products with different coverage and benefit plans unique to the organization served. Additional projects may be assigned to nurse case managers to enhance and support specific quality projects as specified by the director.

Duties and Responsibilities:

1. Assess, plan, implement, coordinate, monitor and evaluate members in order to identify and follow those members who would most benefit by case management and disease management programs specific to the population served.

2. Develop with the member actionable case management care plans based upon (1) identification of problems or barriers that interfere with the member’s health and wellness, (2) develop and implement case management interventions specific to targeted barriers, (3) establish measurable goals and timeframes for completion (4) provide measurable outcomes of case management interventions and (5) reassess and/or evaluate the case management plan of care at regular intervals including progress toward goals.

3. Provide specific documentation all contacts, mode of contact, successful and unsuccessful.

4. Provide telephonic and/or on-site visits to members home to gather data for various forms provided by payers including, but not limited to, health risk assessments, fall risk assessments, Medication Adherence, Medication possession (fills), Retail vs. Mail order, multiple ER visits, Readmissions, High Risk Drugs, Patient Safety projects, CMS 5 Star preventative care, etc.

5. Provide extensive member teaching related to all projects to enhance safety, adherence to medical and medication regimens, increase knowledge of disease process, maintain stability in chronic disease states and arrange for services for those who are unable to afford the care required.

6. Provide member teaching during all contacts with members and monitoring of disease states.

7. Gather case data for the population served, including but not limited to, number identified for CM services, number enrolled, number followed at the facilities, case duration, number declined, long and short term goals met, and positive impact dollars from case negotiation and cost savings using appropriate levels of care.

8. Frequent communication with physicians and physician offices as needed to facilitate and arrange appointments, preventative care, education, condition changes, medication reconciliation and management of chronic disease states as well as other case management interventions.

9. Provide high level review of medications, cost effectiveness and usage of generic medications to enhance medication adherence in the population.

10. Arrange for Patient Assistance Programs (PAPs) as needed.

11. Provide disease management services including education of the disease process and provide educational materials at intervals to support ongoing member education and stability.

12. Educate members on their individualized plan of care, including, but not limited to, their options, rights, and benefit plans (EOC).

13. Coordinate effectively with members and their families, the primary care physician, other case managers, and other care providers to develop, implement, and assess an individualized plan of care.

14. Participate in Interdisciplinary Care Team conferences.

15. Interface and refer complex cases to the corporate Medical Directors.

16. Provide Utilization Review activities systematically including, but not limited to, Precertification, Concurrent Review and Discharge Reviews based upon payer contracts.

17. Successfully pass Inter Rater Reliability measures for appropriate application of all criteria used by the organization.

18. Refer to the corporate Medical Director all cases that cannot be approved at the non-physician level of utilization review.

19. Document all utilization review decisions and referrals to the corporate medical director.

20. Follow up on Medical Director second level of review decisions for utilization timely and provide follow up to facilities, members appropriately until case is adjudicated in the time frame necessary based upon regulatory requirements.

21. Demonstrate consistent proficiency in member assessment, discharge planning, utilization review, and case management services.

22. Demonstrate trustworthiness, honesty, and high personal standards in dealings with others at all times.

23. Show a high level of dedication to a commitment to excellence, working hard to deliver on commitments to others and ensure quality of care.

24. Pay careful attention to detail when reviewing member reports, laboratory results, and physician orders, filling out and submitting required documentation, and securing member records for various program resources.

25. Direct and supervise tasks delegated to assigned non-licensed staff including care coordinators and case management technicians to ensure quality of care.

26. Treat other people, including those of different backgrounds, beliefs, and gender, with fairness and respect.

27. Manage time to accomplish tasks efficiently and effectively.

28. Perform job duties in a reliable, responsible, and dependable manner (e.g., report to work and appointments consistently on time; complete tasks in a timely fashion).

29. Negotiate and advocate on behalf of the members to resolve problems and retain all available services and resources.

30. Establish and maintain cooperative working relationships with others, including members of the health care team, and members and their families.

31. Exhibit maturity and self-control, even in situations involving conflict or stress.

32. Promptly communicate necessary and important information to members and their families, physicians, and other care providers.

33. Work effectively and efficiently under tight deadlines, high member volume, and multiple interruptions.

34. Remain sensitive to members' physical, emotional, cultural, linguistic and psychosocial needs when interacting with them and managing their plan of care.

35. Display knowledge needed for the job, including relevant medical and case management procedures, policies and regulations (CCMC.org)

36. Take the initiative to set goals, create plans, prioritize, and complete tasks, needing little or no supervision.

37. Ensure accuracy when performing tasks, including assessing members, developing and implementing plans for member care, and comparing members' progress with the plan of care.

38. Closely monitor the effectiveness of the current plan of care, identify any barriers that exist, and make appropriate adjustments as needed.

39. Accept feedback without becoming defensive and use it to strengthen future performance.

40. Take responsibility for his/her actions and quality of work without blaming others or making excuses.

41. Other duties as assigned by the director.

Other Requirements: Offsite functions, ICT meetings, IPA and MSO seminars and POD meetings including meetings with our customers, as well as educational events and seminars and to PCP offices in the State of Florida. Traveling to other states may be required, depending upon the corporation’s service level agreements which can change at any time. Estimated percentage of travel: less than 20%.

Qualification: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily with minimal supervision. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience: RN or LPN, working under the direct supervision of an assigned RN, FL state license in good standing with experience in multiple areas within the continuum of care. BSN, CCM, CRRN, case management experience in hospital, SNF or health plan preferred.

Language Ability: Proficient in English, clear speaking ability, bilingual preferred.

Computer Skills: 40 WPM in typing, proficiency in MS Office including Outlook, Excel and Word. Experience with Case Management software including InterQual® Care Enhance Review Manager Enterprise (CERME) preferred. High level of computer proficiency required.

Work Environment:

The noise level of the work environment is usually moderate.

Physical Demands:

The employee must have close vision ability, be able to use the telephone and the computer extensively during the work day. While performing the duties of this job the employee is regularly required to sit, stand, use hands and arms, talk and hear.

Job Type: Full-time

Pay: $18.50 - $23.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Experience:

• Clinical Case Managers: 1 year (Preferred)
• Case management: 1 year (Preferred)

Work Location: One location