Case Manager

 

COMMUNITY HEALTH PLAN

 Case/Disease Manager

 

www.chpw.org

 

KEY RELATIONSHIPS:

 

Reports To:  Manager of Case, Populations and Disease Management

 

 

Other Key Relationships:  (Peer and/or Collaborative):  Director of Care Management, Quality Management Manager, Customer Service representatives, Quality Management staff, Provider Relations staff, Pharmacy staff, Utilization Management (UM) staff, CMO, Corporate  Medical Director,   

 

 

POSITION PURPOSE:

 

This position facilitates effective and appropriate use of health care services by:

 Identifying high risk and high cost patients with complex medical and/or psychosocial needs, assessing treatment options and opportunities and designing treatment programs to improve the quality and efficacy of care;Integrating and coordinating the expertise and support of other professionals family members, community agencies, and providers across the health care continuum;Integrating current best practice guidelines related to catastrophic, acute, and chronic disease management;Achieving optimal clinical and quality outcomes by effectively managing care and resources;Serving as a liaison to centers and center staff regarding case/disease management;Participating in department process improvement efforts;

 

 

 

 

 

PRINCIPLE DUTIES:

 

The duties with either an MSW or RN designation indicate that they are the primary responsibility of that discipline; however, all of the principle duties remain applicable to either discipline.

 Perform review, screening and management of potential case/disease management cases.Complete assessments, plan of care, identify resources and goals with enrollee and family involvement.Assist in resource development for complex cases. Assist in the standardization and completion of psychosocial assessments with complex and or high risk members. (MSW)Assist and consult in enrollee assessment for referral to case, disease, population, or entitlement programs. Maintain enrollee case files in MEDecision and Care Guide QI; recording in timely and comprehensive manner all-relevant case information and updating the Primary Care Provider, as needed, on the enrollee’s condition and discharge plan.  Documentation will include all case management interventions provided, the rationale for the interventions and, when appropriate, the individual providing information regarding the enrollee’s condition.Evaluate each case for cost savings and quality improvement potential; maintain accurate documentation in a timely manner consistent with department policy and procedures.Assist center medical directors, primary care providers and managed care coordinators in case management of complex outpatient cases using Community Health Plan Case Management Process guidelines. (Case Management RN)Manage and maintain requests for authorization/referrals that require Plan approval for cases being actively managed. (Case Management RN)Enter authorizations for Plan-approved services into claims payment system to insure proper payment of claim. (Case Management RN)Provide clarification and feedback to members and providers as needed on benefit coverage determinations. (Case Management  RN)Act as an internal consultant to other departments on Case or Disease Management and clinical resource issues.Visit member clinics as needed to assist in education and information gathering for improved outcomes for Community Health Plan members.Assist in the development of policies and procedures related to the case/disease management function.Review cases with manager or designee on regular basis to assess goals and review case closure criteria.Participate in peer review and audit activities as required.Other duties as assigned.

 

QUALIFICATIONS: Education

Bachelor of Science in Nursing, Masters in Social Work or Licensed Clinical Social Worker required. Current Washington nursing license if RN is required. 

 Prior Related Experience

 

2 + years of experience in case or disease management in a managed care environment; 2 + years in community nursing or medical social work required.

Certified Case Manager preferred.

 

 

·  Eligible to participate in local, state and federal health care programs including Medicare and Medicaid.

 

Knowledge, Skills, and Abilities

Thorough knowledge of Case Management functions;

·  Computer literacy, including familiarity with Windows and Microsoft Office programs;

·  Ability to work independently and in a team environment;

·  Good problem solving skills;

·  Excellent time management skills;

·  Excellent written and verbal communication skills and ability to work well with all types of providers/customers;

·  Ability to maintain professional demeanor and confidentiality;

·  Knowledge of entitlement programs and ability to access. Other

Eligible to participate in local, state and federal health care programs including Medicare and Medicaid.

 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.

·  Frequent torso/back static position; occasional stooping, bending and twisting. 

·  Frequent finger dexterity; occasional simple grasp and wrist flexion. 

·  Occasional stooping, bending and twisting. 

·  Constant sitting, walking, or climbing stairs.

·  Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching.

 

Mental:

·  Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

·  Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

·  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.

 

To apply please use the following link or visit our websiste at www.chpw.org.

 

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

 

 

 

 

EEO/Affirmative Action Employer - M/F/Vet/Disab

 

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