Case Manager/Care Coordinator II (Shelton, Connecticut)

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com

 

JOB SUMMARY: 

The Case Manager/Care Coordinator II is responsible for the coordination of services and cost effective management of health care resources to meet individual members’ health care needs and promote positive health outcomes. Acts as a member advocate and a liaison between providers, members and Health Net to seamlessly integrate complex services.  Case Management services are generally focused on members who fall into one or more high risk or high cost groups and require significant clinical judgment, independent analysis, critical-thinking, detailed knowledge of departmental procedures, clinical guidelines, community resources, contracting and community standards of care. Case Management includes assessment, coordination, planning, monitoring and evaluation of multiple environments.


ESSENTIAL DUTIES AND RESPONSIBILITIES: Participates in programs to proactively identify members at risk who are appropriate for case management services. Reviews, screens and prioritizes cases for possible case management services.Expedites access to appropriate care for members with urgent or immediate needs using expedited review process.Acquires appropriate clinical records, clinical guidelines, policies, EOC, Benefit Policy and coding guidelines. Assesses the member’s current health status, resource utilization, past and present treatment plan and services; prognosis, short and long term goals, treatment and provider options.  Develops plan of care based upon assessment with specific objectives, goals and interventions designed to meet member’s needs.Works with the member/family, provider(s), and other members of the health care team to develop a plan of care that enhances the clinical outcome while maximizing the member’s benefits.Performs evaluation in multiple environments including process and relationships, health care management, community resource and support, service delivery, psychosocial intervention and rehabilitation.Closes cases according to the defined case closure procedure in a timely manner, and in accordance with guidelines established.Identifies potential reinsurance cases and notifies the appropriate department according to policy and procedure.Identifies potential TPL/COB cases, investigate TPL/COB issues and notify the appropriate internal departments.Identifies cases needing Medical Director review or input.  Presents cases to Medical Director for potential review or determinations when needed.Refers potentially inappropriate resource utilization or quality related concerns to Medical Directors.Performs prospective, concurrent and retrospective reviews and first level determination approvals for assigned members, as appropriate, or refers reviews to appropriate associate.  Utilizes considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times and regulatory requirements. Works closely with delegated or contracted providers, groups or entities (as assigned) to assure effective and efficient care coordination. Maintains confidentiality of all PHI in compliance with state and federal law and Health Net Policy.

REQUIREMENTS:

 

Education:

One of the following required: Graduate of an accredited nursing program.Bachelor’s degree preferred for nursing graduates.

Certification/License:Valid & Active Registered Nurse licensure in the State of Connecticut.Case Management certification preferred.

Experience:Minimum three years clinical experience required. One to three years Case Management experience required. Health Plan experience preferred.

Knowledge, Skills & Abilities:Strong knowledge of NCQA, federal and state regulations/requirements. Demonstrated ability for assessment, evaluation and interpretation of medical information, and care planning. Possess a high level of understanding of community resources, treatment options, home health, funding options and special programs. Extensive knowledge of the management of chronic conditions. Experience using standardized clinical guidelines required. Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project.

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

 

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening. 

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.