Care Specialist

To apply for this and other open positions, please visit our website at www.chpw.org or use the following link:

http://tbe.taleo.net/NA8/ats/careers/jobSearch.jsp?org=CHPW&cws=1

 

 

 

COMMUNITY HEALTH PLAN

 

CARE SPECIALIST–

Care Coordination

 

 

KEY RELATIONSHIPS:

 

Reports To:   Manager, Care Coordination

 

Supervises: Non-Supervisory Position 



Other Key Relationships (Peer and/or Collaborative):

 

Case Management Team; Disease Management Team; Utilization Management Team; Director of Care Management; Other Care Management Managers

 

 

 

FLSA: Non-Exempt

 

 

POSITION PURPOSE:

 Assist in development and maintenance of systems to support daily Care Coordination activities and meet monthly reporting requirementsAssist in development and maintenance of systems to support implementation and maintenance of  Health Risk Assessments (HRA)Ensures effective identification of cases to improve members’ health and increase cost savingsAccurate and timely distribution and assignment of prior authorization requests, hospital notifications or claims, and acts as liaison for all Care Management teams in order to ensure the uninterrupted department flow

 

 

PRINCIPLE DUTIES:

 A. Provide daily Hospital Notification support by calling on Hospital Notifications to obtain and enter discharge dates and request reviews as needed. Request appropriate additional clinical or administrative data as needed to complete PEC review.B. Prepares Utilization Management Oversight Group documents, including Disease Management Guidelines, Clinical Practice Guidelines, Routine Care & Screening Guidelines, and Authorization & Referral Guidelines, as well as Care Coordination policies and procedures.C. Categorizes, batches and distributes in-coming documents to Care Coordinators to ensure timely processing.

D. Develops and maintains Care Coordination Desk Procedures and participates in the process of developing and typing departmental policies and procedures.E.  Handles all administrative duties related to the Health Risk Assessment Survey.  This includes compiling member responses to surveys or calls, identifying strategies to improve response and providing reporting on survey results.F.  Provide support to staff to include processing of prior authorizations, creating non-covered benefit and approval letters, and MEDecision tracking and entry.

G. Collects monthly department data on Cost Savings - develops tracking systems, analyzes data (e.g. Balanced Scorecard measures) and creates graphic data displays (e.g. QI outcome measures)

H. Provides back up when the other Medical Management administrative assistants are out of the office. Assures turnaround timelines are met and maintains appropriate documentation of all activities.I.  Participate in clinic trainings/presentations, Clinical Operations workshops and interdepartmental presentations.J. Coordinates performance measures:·  Collects monthly department data (e.g. cost savings)·  Develops tracking systems·  Analyzes data (e.g. Balanced Scorecard measures)·  Creates graphic data displays (e.g. QI outcome measures)K.  Enters new and completed prior authorization requests into the computer system as needed.L.  Maintains and updates department letter templates as needed.M. Perform other duties and participate in projects as assigned for Care Management and other Medical Management units as workload allows.

 Other duties as assigned.



 

QUALIFICATIONS: 

Education and Training: 

High school graduation.  Associate Degree preferred.

 Prior Related Experience

2 years year clerical support experience. Healthcare or managed care experience preferred.  Experience and expertise using MS Word, Excel, Access and Power Point.

 

 

Employment Eligibility:

Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

 

Knowledge, Skills and Abilities:

·  Excellent customer service skills (both internal and external customers), including the ability to work with people of diverse backgrounds in a respectful and courteous manner at all times.

·  Demonstrated written communication skills, particularly in the area of drafting and editing memos and letters.

·  Ability to prioritize, organize and complete daily work both independently and with team members with routine supervision. 

·  Ability to maintain a professional demeanor at all times.

·  Ability to maintain confidentiality.

·  Flexibility and ability to follow through on assigned tasks with minimal direct supervision.

·  Excellent interpersonal and team skills.

·  Expert computer skills that include:  word processing, graphic reports, spreadsheets and database development and maintenance

 

 

 SENSORY/PHYSICAL/MENTAL REQUIREMENTS

 

Sensory:

·  Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

 

Physical:

·  Extended periods of sitting, computer use, talking and possibly standing.

·  Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.

Mental:

 

·  Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

 

WORK ENVIRONMENT

Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.

 

PROTECTED HEALTH INFORMATION (PHI) ACCESS

Community Health Plan employees will encounter protected health information in the regular course of their work at and for Community Health Plan. Community Health Plan is a Covered Entity engaging in Health Care Service Contractor treatment, payment and operations. The following scale intends to provide some indication of how often the employee may encounter or work with PHI in this particular role.  All PHI shall be used and disclosed on a Need To Know Basis and according to HIPAA Privacy Rules Part 164.  In addition, every employee shall sign a confidentiality agreement as a condition of employment and violation of that agreement and/or Community  Health Plan policies can be cause for termination. 

 

PHI is defined at 164.103 as:

"Protected health information means the individually identifiable health information that is (i) Transmitted by electronic media; (ii) Maintained in electronic media; (iii) Transmitted or maintained in any other form or medium.

Individual means the person who is the subject of protected health information.

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

This position as described will use, encounter, read, create, disclose and or work with in general, PHI that is created by or received by Community Health Plan:

 Frequent - The position has frequent and/or daily access and responsibility for PHI.Need to know.

In all cases, PHI use and disclosure is limited to the minimum necessary amount of PHI needed to complete the treatment, payment or operations.

 

The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.

 

 

.