Company: FirstCare Health Plans
Posted on: February 12, 2019
SUMMARY: The Case Manager participates as a member of the FirstCare Care Management team. The Case Manager works to ensure optimal member health outcomes by applying the case management process in collaboration with other members of the interdisciplinary team. ESSENTIAL DUTIES and RESPONSIBILITIES:
- Serves as the primary point of contact for the member/caregiver and the other members of the team. Develops and maintains professional working relationships with PCPs, physician's office staff and clinicians, community resources, employers, and other health care providers.
- Assesses the needs of members and utilizes data obtained from a variety of sources to develop an individualized plan of care for the member. Incorporates participation of the member/caregiver and other members of the interdisciplinary team in care plan development.
- Evaluates available member benefits to identify and implement care options to improve quality of life, reduce the cost of care and ensure efficient utilization of resources. Determines and provides/arranges for the appropriate level of support to meet the member needs, ranging from self-management education to End of Life services; varying outreach frequency as member needs change.
- Participates in case reviews and collaborates with other FirstCare team members (Medical Director, Pharmacist, UM team, Supervisor) as needed to find solutions to meet the needs of Members.
- Collaborates and coordinates with member or caregiver, primary care physician, members of the health care team, and community caregivers to develop member support systems and achieve recommended delivery of services for chronic and catastrophic care coordination.
- Implements member care plans within legal and regulatory parameters and in consideration of member factors. Appropriately delegates tasks to other members of the case management team in accordance with applicable licensure requirements.
- Educates the member, the family or caregiver and members of the health care delivery team in accordance with the plan of care about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made.
- Identifies and addresses alterations in the member response to care plan interventions in comparison to desired outcomes.
- Completes care management documentation according to NCQA standards and department procedures. Maintains up-to-date case management case status and labeling in the case management information system.
- Maintains current knowledge of NCQA, regulatory (CMS, State Department of Insurance, HHSC), and Texas Board of Nursing rules and standards relative to care management; consistently delivers care management services in compliance with these standards.
- Participates in organizational and health system quality improvement and program activities as assigned by supervisor.
- Performs other duties as assigned. EDUCATION AND EXPERIENCE, CERTIFICATES, LICENSES, AND/OR REGISTRATIONS:
- Current, valid Registered Nurse or Social Worker licensure in the State of Texas
- Graduation from an accredited school of nursing or social work
- For Social Worker: Minimum Bachelor's Degree in Social Work required
- For Nurse: Associate's Degree or Certificate in Nursing with at least five years practice experience required. Bachelor of Science in Nursing (BSN) preferred.
- Experience in managed care medical management functions and procedures strongly preferred
- Case Management Certification preferred
- Computer skills with basic understanding of Microsoft Word, Excel and PowerPoint SKILLS AND ABILITIES: Communication High: ability to communicate complex information in verbal and written form and explain complicated information in simple descriptions; ability to interface with providers, internal staff, mid-upper management professionals, and general public. Analytical Moderate: gathering, analyzing, interpreting data according to standard methods, guides, and procedures. Proofreading completed work to find and correct errors. Requires excellent attention to detail. Other Skills and Abilities
- Independent judgment, decision-making, problem solving related to technical systems, interpreting policies and/or procedures to fit day-to-day operational situations occurring within the department.
- Demonstrate excellent working knowledge of software systems used daily.
- Organize and manage time to accurately complete tasks within designated time frames in fast paced environment.
- Must have appropriate computer skills with basic understanding of Microsoft Word and Excel.
- Maintain current knowledge of and comply with regulatory standards and company policies& procedures.
- Maintain confidentiality of patient and business information.
- Flexible: ability to adjust work hours to meet business demands. SCHEDULING Frequent influx of high workloads throughout the year, with heavy volumes during peak periods. Occasional travel which may require use of personal auto to attend meetings, conferences, workshops, and/or seminars. FirstCare Health Plans is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetics or any other basis prohibited by law.
Keywords: FirstCare Health Plans, Lubbock , Case Manager, Executive , Lubbock, Texas
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