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JOB SUMMARY: The SNP Case Manager position is a full time position that is responsible for conducting case management, disease management, care coordination 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.
Adheres to Special Needs Program-Model of Care 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;
Must become knowledgeable of URAC requirements for Case Managers for CM accreditation;
Performs telephonic case management and care coordination activities, communicating with the multidisciplinary team in the timeframes required to meet program goals and objectives;
Performs telephonic assessment in accordance with Health Integrated policy and procedure
Collects pertinent clinical information (including specific claims data when available), documenting findings using the HI case management information system program/hard copy charting;
Summarizes and documents 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;
Serves as a patient advocate when deemed applicable or as requested by the patient/patient's legally appointed representative; and,
Initiates patient assessment.
Assess the client's strengths, problems, prognosis, functional status, goals and need for specific services/resources, to establish short-term and long-term goals.
Develops a plan, when indicated, through interdisciplinary collaboration which identifies options and goals.
Identifies, procures and coordinates services and resources necessary to implement the individual's plan.
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.
Consults with the designated Medical Director regarding member cases with question about appropriateness of care, evidence based care guidelines, medication questions, practitioner care plans, etc. Refers cases to HI legal and/or health purchaser’s legal staff where there is a threat of litigation and/or those patient's specified by the legal department for immediate referral;
Identifies, in collaboration with the patient/patient's legally appointed representative, practitioners, other health care providers, health purchaser, the multidisciplinary team members and/or the HI Chief Medical Officer/Medical Director, the resources that will be required to meet/manage the patient's level of care/acuity of care requirements;
Identifies and communicates to supervisor/director, all hospital ancillary providers, physician providers and physician offices, any concerns related to patient safety;
Develops, monitors and updates an individualized member care plan in collaboration with the patient/patient's legally appointed representative, practitioners, and the multidisciplinary team members;
Sets realistic, short and long-term goals for the patient as the care plan is developed and/or revised;
Monitors the care 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;
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 hospital discharge planning/social worker staff;
Readily available to non-clinical staff to answer questions and ensure that non-clinical staff is performing within the scope of the non-clinical role
Creates and supports a positive and supportive working environment;
Identifies and resolves potential personnel/peer problems and issues proactively;
Communicates to Manager and/or Director 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 SNP-MOC team meetings;
Actively participates in any Health Integrated committee meetings as assigned; and,
Serves as a positive role model for peers.
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 based on HIPAA guidelines
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.
A bachelors (or higher) degree in a health-related field preferred.
Case Management certification within three years of employment required.
Current, unrestricted RN required.
Three (3) years clinical practice experience required.
Practice case management and/or disease management within the scope of their licensure (based on the standards of the discipline)
Two-three years clinical experience in case management or acute hospital discharge planning preferred;
Three years full-time direct clinical or critical care to patients in a medical/surgical or behavioral health setting; or
Three years of experience in applying healthcare criteria or a behavioral health set of criteria
Call center knowledge desirable
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 typing and 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 management in a professional and timely manner.