Responsible for carrying out case management activities for IPA members referred to the case management program across all levels of care. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet the client’s health and human service needs. It is characterized by advocacy, communication and resource management and promotes quality and cost-effective interventions and outcomes. Case management activities are based on nationally recognized case management standards and concepts and principles. All contacts are telephonic with an option for on-site case conferences as needed.
- Identification of members appropriate for case management, based on identification of health-related problems.
- Assessing members’ physical and psychosocial needs/barriers.
- Developing the case management care plan.
- Developing and implementing the interventions needed to resolve barriers and coordinate care, allowing members to accomplish their goals with physician guidance and supervision.
- Documenting assessments, care plans, interventions, and all other activity related to coordinating the care of case-managed members.
- Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
- Maintain department procedure/policy standards with regard to turnaround time, etc.
- Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes.
- Coordinate internal and external resources for the individual member.
- Maintain and update a community resource database.
- Document all case management activities in the HPMG case management online system.
- Utilize existing reports and systems to identify and monitor utilization resource patterns and facilitate needed care coordination in order to support Quality Improvement.
- Refer to various departments for supportive interventions, i.e., Health Education, Quality Management, Contracting, Provider Services, Client Data Management, TPL, COB, etc.
- Issue letters of explanation in accordance with department policy.
- Support Medical Management Team, Authorization Review, Clinical Initiatives, and Provider Education.
- Attend and participate in in service programs and conferences that support practice of case management.
- Perform other duties as assigned.
- Minimum 3 – 5 years of experience required
- Minimum three years clinical nursing experience in an area such as medical surgical, critical care, home health or skilled nursing, and;
- Two years of experience in case management, utilization management, discharge planning and or quality improvement in a managed care setting
- Experience with managed care delivery including IPA networks and Medicare.
- Optimum organizational skills with ability to meet both expected and unexpected time frames.
- Excellent verbal and written communication skills.
- Ability to coordinate effectively with a variety of customers including members, providers, office staff, health plans, internal department, community resources, and peers.
- Ability to work independently with self-initiative and discipline.
- Knowledge of ICD-10 and or CPT coding.
- Working knowledge of personal computers.
- A.S. degree
- Unrestricted California Registered Nurse licensure; certification in case management preferred.
Hill Physicians is an Equal Opportunity Employer
Electronic Medical Record
Patient Care Coordination