NEW OPPORTUNITY - COMPLEX CASE MANAGER
Co-Morbid Case Management (CMCM) is an Enhanced Care Management Program focusing on high risk, co-morbid aged; blind and disabled Medicaid members utilizing face to face nurse case manager visits integrated with a MultiDisciplinary Team (MDT) and the member's primary care physician in an effort to enhance care quality and reduce medical utilization. Positions are located in both the Harrisburg and Pittsburgh markets.
The ESSENTIAL RESPONSIBILITIES for the CMCM Complex Case Manager are:
- Comprehensive management of members with a CoMorbid illness.
- Proactive management with the objective of improving quality outcomes and decreasing costs.
- Early identification and assessment of members for admittance to a comprehensive case management program.
- Apply case management concepts; principles; and strategies in the development of an individualized case plan that addresses the member's broad spectrum of needs. The case planning process includes the following actions: initial home visit; assessment; goal setting; establishing interventions related to goals; monitoring success of the interventions; evaluating the success of the overall case plan; and reporting outcomes.
- Interviews members telephonically; in the physician's office; home visits or in other facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the member's primary care physicians; other providers including behavioral health providers; health plan Medical Directors; health services staff and to MultiDisciplinary Team.
- Serves as the member's advocate to ensure they receive all necessary care allowed under their benefit plan. Develop knowledge of community resources and alternate funding arrangements available to the member; when services are not available under their benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing their lengths of stay.
- Develops relationships with hospital social workers and community resources to assure appropriate management of catastrophic and chronically ill members.
- Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective healthcare and the preservation of the member.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- May serve as a consultant to the physician network(s) to insure overall improvement in quality of medical care and outcomes.
- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management; case management; and general medical issues.
- Maintains confidentiality of member's information in accordance with HIPPA regulations. Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active state license.
- Bachelor’s degree or equivalent experience preferred.
- Complies with all state certification requirements in the state where job duties are performed.
- Previous experience (usually 1+ year) in case management.
- Significant experience (usually 3+ years) clinical experience.
- If required by URAC/NCQA accreditation, or the health plan, case management certification must be obtained within 4 years of date of hire.
- Utilization management experience and knowledge of community resources preferred.
- Experience with using computer systems as part of the clinical activity.
- Regular local travel may be required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: , PA, US
Other Locations: Harrisburg-Pennsylvania-United States,Pittsburgh-Pennsylvania-United States
Organization: 10900 - CMS - STAR Corporate
Schedule: Full-time
Job Posting: 2013-01-02 00:00:00.0
Job ID: 1310008