Improve the health status and quality of life of members with complex medical and behavioral health conditions through a needs assessment and coordination of resources to optimize overall health. The scope of case management includes, but is not limited to, assessing needs, connecting members with the appropriate level of care; proactively and timely, actively monitoring members at-risk, and offering condition-specific education and guidance for optimal health outcomes.
The goals are to:
Return members to optimal level of health and functioning with maximum level of independence
Increase member and provider satisfaction through collaboration on the development and implementation of the case management individualized care plan.
Perform the comprehensive assessment of high-risk members, including evaluation of physiological, functional, psychosocial, environmental, financial, caregiver capability, and medication lists and compliance.
Collaborate with the primary care provider to ensure the implementation of an individualized, comprehensive care plan with specific interventions designed to engage the member, provider, and family/significant others. The Case Manager addresses, identifies, and continuously reassesses cost-efficient, appropriate levels of care.
Put non-medical community based support services in place to ensure compliance with treatment plan, (i.e. housing, transportation, entitlements).
Coordinate planned and unplanned transitions from members’usual setting of care to the next setting as defined by individual member needs. Communicate the care transition process with the member or responsible party.
Participate with the attending physicians, primary care physicians, social workers, and discharge planners in transitioning patients to the most appropriate level of care.
Participate in MM case rounds and MM departmental staff meetings
Record ongoing clinical, functional, quality of life, satisfaction, and fiscal outcomes during the management process. The ICM assessment process fosters the development of an alliance between the case manager and patient/client using motivational interviewing skills while disentangling physical, psychological, social, and health system barriers to improvement.
Participate in QM studies as directed.
Enhance communication and collaborative relationships with multidisciplinary healthcare team members.
Emphasize continuity of care, thus reducing or eliminating fragmentation, duplication, and gaps in treatment plan.
Act as a patient advocate protecting privacy and confidentiality issues.
Provide patient education, monitoring of health needs, and coordination of community resources.
Prevents adverse patient occurrences when possible and intervenes quickly if prevention is not possible, thereby minimizing poor outcomes.
Collect quality review data to support outcome measurements. Maintain a comprehensive working knowledge of community resources and network services for target population.
Identify opportunities for health promotion and illness prevention.
Participate in MM Department projects per the direction of the Director Medical Management.
Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
Performs other duties as necessary or assigned.
Current NY RN License or other related professional license
Bachelors or Associates degree in a related field preferred
Certified Case Manager is preferred.
Minimum of five (5) years Med/Surg experience; hospital setting preferred.
Minimum two (2) years experience in Utilization Management, Discharge Planning, Case Management or Home Care.
Excellent oral and written communication skills as demonstrated by the ability to convey precise, technical information clearly and concisely.
Special interpersonal skills that foster positive working relationships with internal and external customers, including a pleasant telephone manner.
Ability to analyze and integrate complex medical information and make sound decisions.
Resourcefulness as demonstrated by the effective application of professional knowledge to new situations.
Demonstrated ability to make sound decisions based upon established guidelines.
Strong organizational and prioritization skills as demonstrated by the ability to handle multiple tasks concurrently
Proficient with Microsoft Office applications; Facets experience preferred.
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