Day to day responsibilities: Manage a caseload of approximately 75-90 MyCare Ohio Waiver Members. This includes both telephonic contact and in person contact with members in their home. The Care Manager is responsible for managing the member’s health care and waiver services.
Summary: Responsible for health care management and coordination of Healthcare members in order to achieve optimal clinical, financial and quality of life outcomes. Works with members to create and implement an integrated collaborative plan of care. Coordinates and monitors members progress and services to ensure consistent cost effective care that complies with policy and all state and federal regulations and guidelines.
Essential Functions: Provides case management services to members with chronic or complex conditions including: o Proactively identifies members that may qualify for potential case management services. o Conducts assessment of member needs by collecting in-depth information from information system, the member, members family/caregiver, hospital staff, physicians and other providers. o Identifies, assesses and manages members per established criteria. o Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals to address the member needs. o Performs ongoing monitoring of the plan of care to evaluate effectiveness. o Documents care plan progress in information system. o Evaluates effectiveness of the care plan and modifies as appropriate to reach optimal outcomes. o Measures the effectiveness of interventions to determine case management outcomes. Promotes integration of services for members including behavioral health and long term care to enhance the continuity of care for members. Conducts face to face or home visits as required. Maintains department productivity and quality measures. Manages and completes assigned work plan objectives and projects in a timely manner. Demonstrates dependability and reliability. Maintains effective team member relations. Adheres to all documentation guidelines. Attends regular staff meetings. Participates in Interdisciplinary Care Team (ICT) meetings. Assists orientation and mentoring of new team members as appropriate. Maintains professional relationships with provider community and internal and external customers. Conducts self in a professional manner at all times. Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct. Participates in appropriate case management conferences to continue to enhance skills/abilities and promote professional growth. Complies with required workplace safety standards.
RN day to day responsibilities: Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts inpatient reviews to determine financial responsibility for Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. Requests additional information from members or providers in consistent and efficient manner. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote Care Model. Adheres to UM policies and procedures.
Knowledge/Skills/Abilities: Demonstrated ability to communicate, problem solve, and work effectively with people. Excellent organizational skill with the ability to manage multiple priorities. Work independently and handle multiple projects simultaneously. Strong analytical skills. Knowledge of applicable state, and federal regulations. Knowledge of ICD-9, CPT coding and HCPC. SSI, Coordination of benefits, and Third Party Liability programs and integration. Familiarity with NCQA standards, state/federal regulations and measurement techniques. In depth knowledge of CCA and/or other Case Management tools. • Ability to take initiative and see tasks to completion. Computer skills and experience with Microsoft Office Products. Excellent verbal and written communication skills. Ability to abide by policies. Able to maintain regular attendance based upon agreed schedule. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers. Required Education: Bachelors degree in Nursing or Masters degree in Social Work, or Health Education (a combination of experience and education will be considered in lieu of degree). Required Experience: 0-2 years of clinical experience with case management experience. Required Licensure/Certification: Active, unrestricted State Registered Nursing license or Licensed Clinical Social Worker LCSW or Advanced Practice Social Worker APSW in good standing. A combination of experience and education will be considered in lieu of LCSW or APSW. Must have valid drivers license with good driving record and be able to drive locally.
Electronic Medical Record
Long Term Care