Coventry’s Medicaid Division is seeking an experienced RN Case Manager to join our team in Louisville in the role of Transitional Care Case Manager. This individual will work collaboratively with members of an interdisciplinary team such as the attending physician, specialists and other ancillary providers. He or she will also work closely with plan pharmacists to determine any medication adherence or reconciliation concerns that could adversely affect the member's recovery from an inpatient admission. The program goals include reduction of readmissions; improved physician follow up and increase in member knowledge of their condition and medications. The position is located in the Louisville market and will require visits to member homes.
- Responsible for the short term management of members identified for the transitional care program by program and condition.
- Responsible for the proactive management of chronically ill members with the objective of improving quality outcomes and decreasing costs.
- Responsible for the early identification and assessment of members for admittance to a short term chronic care management program.
- Applies 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: 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 their home; physician office or in other facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the plan pharmacists and health plan Medical Directors; health services staff regarding the status of a particular member.
- Serves as the member advocate to ensure they receive all necessary care allowed under their benefit plan. Develops 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 benefits.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- Collaborate with plan and corporate case managers and social workers as well as plan concurrent review nurses to promptly identify potential cases and refer cases on at the end of the program.
- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management; case management; and general medical issues.
- May be responsible for handling sensitive appeal cases that involve complex medical issues assuring all regulatory requirements are met. Works closely with senior management and the Legal Department on these cases.
Qualifications:
JOB SPECIFICATIONS
- Kentucky Registered Nurse with active, unrestricted 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 will 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: , , US
Organization: 10900 - CMS - STAR Corporate
Schedule: Full-time
Job Posting: 2013-02-07 00:00:00.0
Job ID: 1310500