Medical Case Manager

EXL - Tampa, FL3.8

Why join EXL?

At EXL, were more than just an analytics, operations management, and technology Company. We focus not only on our outstanding Team Members, but on our growing industry as well.

Headquartered in NYC, EXL has more than 27,000 professionals situated in locations throughout the United States, Europe, Asia, Latin America, and South Africa.

Our EXL Team Members receive the benefit of:
Valuable Compensation Package:
Competitive Wages
Work-Related Expense Reimbursement
Annual Discretionary Bonuses
Team Member Referral Bonuses

Comprehensive Health & Welfare Benefits:
Group Medical, Dental and Vision Benefits
Flexible Spending Accounts and Health Savings Accounts
Generous Paid Time Off, Sick Days and Holiday Pay
Group Life Insurance, LTD and 401k Retirement

Inviting Culture & Team-Oriented Philosophy:
Exciting Work Environment
Casual Dress Code
Monthly Team and Company Events
Team Member Appreciation Awards
Remote, Home-Based Opportunities
Opportunities for Upward Mobility

The Medical CM Clinician position is responsible for conducting case management telephonically or onsite based on contractual language and any related utilization management and quality activities in accordance to HI policies and procedures. The position responsibilities include the management of assigned cases to ensure costs are contained and quality of care is maintained as the patient accesses care and services in the continuum of care.

Case Management, according to the Case Management Society of America, is defined as; “a collaborative process of assessment, planning, facilitation for options and services to meet an individual's health needs through communicating available resources to promote quality cost-effective outcomes.” This service is recognized as an organized process designed to ensure the medical necessity and cost effectiveness of a proposed service. Case Management is designated to promote optimal recovery and rehabilitation by professional involvement in the rehabilitation process.

Performs telephonic and/or onsite case management activities, with members or clinics per client contracts.
Communicating with the multidisciplinary team in the timeframes required to meet program goals and objectives;
Adheres to CM program goals and objectives in health care cost containment while maintaining a high quality of health care delivery system to meet the patient's individualized health care needs through adherence to program policies and procedures.
Assess, evaluate and implement member centric care plan with time frames that meet URAC and NCQA requirements
Assess the client's strengths, problems, prognosis, functional status, goals and need for specific services/resources, to establish short-term and long-term goals.
Educates members on any knowledge deficits relative to the complex needs identified
Collects pertinent clinical information (including specific claims data when available), documenting findings using the HI case management information system program
Summarizes and documents within the designated HI care management system pertinent verbal discussions with the patient/patient's legally appointed representative, family, practitioner, other health care provider or the health purchaser staff, and/or any case conferences;
Promotes alternative care and funding programs and researches available options to maximize health benefits and/or replace limited or excluded benefits;
Promotes appropriateness of resources/placement when alternative level of care is required;
Communicates directly with the patient/patient’s legally appointed representative, practitioner, other health care providers and team members when appropriate to gather all clinical information to determine the medical necessity of requested or needed health care services;
Knowledgeable of URAC and NCQA requirements for Case Managers for CM accreditation;
Serves as a patient advocate when deemed applicable or as requested by the patient/patient's legally appointed representative; and,
Provides ongoing evaluation of the individual's progress, effectiveness of the rehabilitation plan, as well as, the efficacy and appropriateness of the services provided.
Advocates on behalf of the individual to assure quality of care and attainment of appropriate goals.
Promotes individual's self-advocacy skills to achieve maximum self-sufficiency.
Communicates directly with the designated Medical Director or Physician Advisor or the Chief Medical Officer regarding all care/costs that:
Are experimental/investigational;
Are beyond the dollar amount or scope allowed for the individual case manager;
Are requested/required out-of-network;
Are required over a prolonged period of time and an extended authorization for care is deemed appropriate for meeting a patient's individualized health care needs.
Refers cases to HI legal and/or health purchaser’s legal staff where there is a threat of litigation and/or those patients specified by the legal department for immediate referral;
Recommends, coordinates or educates regarding alternate care options for patients, families, practitioners, providers or other members of the multidisciplinary health care team;
Identifies any teaching required by the multidisciplinary health care team before the care/alternative level of care can be implemented;
Monitors the CM Plan at regular time intervals and/or at the time frequency dictated by the patient's level of acuity, making recommendations for change when opportunities are identified and/or as the patient's illness/health care needs improve or deteriorate;
Assist in redirecting members to in network providers for services
Negotiates discounts or reduced charges when an out-of-network provider is required to manage the level of care/acuity of the case at hand and/or in accordance to health purchaser contractual requirements;
Maintains an active role in assuring continuity of care for patients through early identification and appropriate discharge planning by close and frequent collaboration with the Health Integrated Utilization Management staff and/or hospital discharge planning/social worker staff;
Closes stabilized cases following collaboration with CM Supervisor and/or Chief Medical Officer/Medical Director
Make referrals to additional programs as needed for graduated complex members, Disease Management, Synergy

Customer Services-Internal
Creates and supports a positive and supportive working environment;
Identifies and resolves potential personnel/peer problems and issues proactively;
Effectively communicates to CM Supervisor, Manager and/or Sr Director CM all problems, issues and/or concerns as they arise;
Maintains a courteous and professional attitude when working with all HI staff members and the management team;
Actively participates in any CM team meetings;
Actively participates in any UM and CM committee meetings as assigned; and,
Serves as a positive role model for peers.

Customer Service-External
Works, communicates and collaborates in harmony and in a courteous and professional manner with patients, practitioners/providers, health purchaser clients and their staff, and the HI multidisciplinary team;
Timely processes and communicates, identifies and resolves all issues and concerns related to the day-to-day case management activities as assigned/designated;
Communicates appropriately and according to HI policy, and/or regulatory requirements with the practitioners, providers, patients or their legally appointed representatives, and/or the health purchaser’s UM/Member/Customer Services or claims staff, regarding CM issues or UM coverage Determinations;
Serves as liaison and patient advocate when deemed applicable for quality of care and cost outcomes; and,
Maintains a working knowledge of the health purchaser contracts and relevant regulatory requirements.
Strong communication, documentation, clinical and critical thinking skills and problem-solving skills are essential;
Working knowledge of community resources and alternate funding resources;
Working knowledge of details/resources that are required to individualize a case, contain costs and maintain quality of care for persons with a catastrophic or high-cost illness or injury;
Strong problem-solving, decision-making, and negotiating skills are essential;
Strong skills in dealing with difficult and challenging personalities and situations are essential;
Excellent computer skills, and ability to collect data as assigned for reporting purposes;
Ability to communicate and work with a multidisciplinary team (internal and external) to facilitate day-to-day workflow; and,
Ability to recognize and communicate any concerns or issues to CM Supervisor in a professional and timely manner

A Bachelors (or higher) degree in a health-related field preferred.
Case Management Certification within three years of employment required.
RN or LPN with a current, unrestricted license to practice as a health professional in a state or territory of the United States required.
Bi-lingual preferred

Wiork Experience Requirements:
Three years clinical experience in acute hospital setting
Prior Case Management experience
Health plan knowledge preferred
EEO Statement