Healthcare Consultant I

Our Client, a Retail Pharmacy Company, is looking for Healthcare Consultant I for their Miami Dade county location

Responsibilities:

• Case Management Coordinator is responsible for telephonically and/or face to face assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness.
• Case Management Coordinator will effectively manage a caseload that includes supportive and medically complex members.
• Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration.
• Case Management Coordinators will determine appropriate services and supports due to member's health needs; including but not limited to: Prior Authorizations, Coordination with PCP and skilled providers, Condition management information, Medication review, Community resources and supports.
• Coordinates case management activities for Medicaid Long Term Care/Comprehensive Program enrollees.
• Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources.
• Conducts comprehensive evaluation of Members using care management tools and information/data review
• Coordinates and implements assigned care plan activities and monitors care plan progress
• Conducts multidisciplinary review to achieve optimal outcomes
• Identifies and escalates quality of care issues through established channels
• Utilizes negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs
• Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health
• Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices
• Helps member actively and knowledgeably participate with their provider in healthcare decision-making
• Monitoring, Evaluation and Documentation of Care:
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures
• Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively
• manage healthcare costs and improve healthcare program/operational efficiency involving clinical issues