Responsibilities Provide comprehensive telephonic case management to targeted population who are identified with chronic diseases, as well as medically complex members referred for outreach.
Develop a tailored plan of care that supports the needs of the members, influences adherence to treatment, assist with discharge planning as needed and care coordination to ensure optimal outcomesApply nationally recognized clinical evidence-based guidelines and best practices approach to identify and address gaps in careCommunicate effectively with members, physicians, and providers; facilitate, advocate, and educate on the disease process; be a liaison and provide referrals to other departments and programs as neededUse of information technology; navigate within care management application and document management systems and maintain accurate documentation of case management assessment, planning, goals and interventions.Act as a Subject Matter Expert based on particular disease management areas of expertise: facilitate ongoing staff training, provide information regarding medications updates and continued educationInterpret reports, understand trends and target specific high risk population, provide recommendations, generate outcomes.Promote active members involvement regarding their health care management and ability in navigating health care delivery systems in order to preserve benefit resourcesAuthorize vendor services using clinically proven criteria to make consistent care decisionsIdentify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered servicesResponsible for abiding by and supporting the care management programs in order to ensure quality and efficient clinical operationsUse industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approachPerform additional duties and projects as assigned by managementMust meet performance standard including attendance and punctualityQualificationsValid New York State Registered Nurse (RN) requiredMinimum three (3) years Medical/Surgical experience plus a minimum of two (2) years Case Management/Disease Management experience requiredBSN and Certification in Case Management a plusKnowledge of HEDIS, NCQA, QARR a plusStrong knowledge of Clinical evidence-based guidelines, industry standard Utilization Management criteria (Milliman Care Guidelines), Medicare and coverage guidelines, health claims processing, medical codingExcellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capabilityComputer and organizational skills required, ability to manage competing priorities, multi-task with results oriented outcomes and work in a fast paced environment.
Intermediate skills of Microsoft Office systems preferred.