POSITION SUMMARY
Works with internal and external health care team to provide oversight of care coordination activities and promote effective and appropriate utilization of services and management of members in Case Management.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the utilization management processes, programs and services are accomplished in a timely and efficient manner, in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including Centers for Medicare and Medicaid (CMS) and/or Department of Health Care Services (DHCS).
RESPONSIBILITIES
- Conducts home visits for identified members.
- Oversight of an assigned caseload and care coordinators.
- Monitors, reviews and coordinates proposed inpatient, outpatient and specialty service requests for members in Case Management and determines covered benefits based upon lines of business benefit structures.
- Develop and maintain accurate documentation pertinent to member care coordination.
- Document all activities required in CHGNet Case Management application and QNXT Call Tracking system.
- Monitors inpatient and outpatient care and facilitates transition to the most appropriate levels of care.
- Ensures that members in Case Management have appropriate access and monitors compliance to treatment plans.
- Contribute to the team effort, maintains member confidentiality.
- Maintain company and product reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating in committees and meetings; performing other duties as required or assigned.
- Conducts necessary outreach to members in Case Management for education on compliance with prescribed treatment plans.
- Assists providers and staff in the identification of chronic care, case management and disease specific management options for identified members.
- Participates in Quality Improvement Activities (QIA) activities. Forwards quality of care concerns to the QI Department and provides case-specific follow-up for pre- determined cases.
- Researches and assists in the implementation of processes surrounding workflow and internal guideline development designed to enhance member outcomes and increase customer satisfaction.
- Attends department meetings; provides feedback for existing processes; maintains patient confidentiality; represents department in interdepartmental and external meetings and forums on request.
- Works closely with internal and external customers at assigned hospitals, clinics, and providers in order to facilitate and improve coordination of care. Provides education to members and providers on available resources. Offers assistance to peers when needed.
- This position requires occasional travel within the San Diego County area.