Conducts care management program activities in accordance with departmental, corporate, state, federal and accreditation standards, as well as CMS standards if appropriate to the member's case assignment. Uses a systematic approach to identify members meeting program criteria, assessing opportunities to coordinate education, support, coaching, care coordination and treatment options, and collaborating with providers. Implements the Care Management processes as appropriate to each individual member in order to facilitate quality, cost effective medical and benefits management.
May participate in a co-located, cross functional, multi-disciplinary team to identify and implement cost saving opportunities to ensure optimal and cost-effective health outcomes. Collaborates with interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member's needs and mitigate health care cost drivers.
Handles a subset of member clinical condition management programs.
Maintains knowledge of current CMSA Standards, Care Continuum Alliance Standards, Member Care Management Program activities, and performs the activities as directed by departmental policy and leadership, current Department of Health regulations/benefits for Managed Medicaid and Family Health Plus programs, and current CMS regulations and standards if managing members of Medicare programs
Carries out job responsibilities in accordance with departmental, corporate, state, federal and accreditation standards, as well as within the scope of practice and licensure as outlined in the New York State Nurse Practice Act, Article 139. Maintains confidentiality and conducts information management procedures per corporate and departmental policy.
Implements the Care Management Process per department policies, procedures and guidelines. Facilitates quality, cost effective medical and benefits management. The process includes case identification, case opening, member assessment, education and support intervention opportunities, developing care plans, conducting interventions, measuring member outcomes during re-assessment, case closure, and case reviews.
Screens members that fall within the defined populations served, referred to the department, either by data analysis (i.e. high-dollar or frequent inpatient trigger reports) or by internal or external referral sources. Applies care management criteria and professional clinical judgment to determine a member's appropriateness for care management services. Investigates members that are appropriate.
Initiates the care manager's role, as outlined in the Member Care Management Program Description, while providing care management services to members. Opens appropriate cases timely and effectively. Assures essential information that relates to care management is disclosed to members, thus increasing the opportunity for success of member outcomes.
Works in collaboration with members' physicians and other health care providers to assess the needs of the member, facilitate development of an interdisciplinary plan of care, coordinates services, evaluates effectiveness of services and modifies the member plan of care as necessary. Maintains positive working relationships within this arena.
Assesses member/family knowledge of his/her illness and initiates appropriate education interventions in an attempt to correct knowledge deficits.
Collaborates with member to determine specific objectives, goals and actions to address program needs identified during assessment.
Provides appropriate resources and assistance to members with regards to managing their health care across the continuum of care. Maintains updated information related to appropriate community resources and serves as an information source for providers and other members of the health care team, and as a liaison between such providers and the community resources staffs.
Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Examples: Utilization Management, Quality Management, and Behavioral Health Department.
Accepts responsibility for continuing education relative to professional growth. Meets or exceeds the minimum continuing education requirements as set forth by departmental and corporate policy, and by individual professional certification standards, if applicable.
Conducts case management statistics, cost effectiveness, and reinsurance reporting. Accurately tracks and reports time usage related to cases managed for contracted services, to ensure accurate invoices are generated for reimbursement of such services upon request.
May work some evening hours, as needed, to accommodate member availability for discussion.
Participates in and promotes other health plan programs, such as, Health Promotion, Medicare, Behavioral Health and FLRx, performing liaison activities with the provider network as directed by department leadership.
Participates in the education and in-services to network providers, support staff and members as part of the plan of care or program development.
Work collaboratively with all Care Managers, especially those with varied clinical expertise (ex. Social Work, Respiratory Therapy, Geriatrics, etc.) to ensure continuity and coordination of care.
May work with internal and external stakeholders for value-based payment programs, such as accountable cost and quality arrangements (ACQA).
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Level II - (in addition to Level I essential responsibilities/accountabilities):
Handles all member clinical condition management programs.
Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
Mentors junior staff & assists with coaching whenever necessary.
Provides consistent positive results of audits.
Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health.
Manages more complex assignments; larger caseloads and a greater number of facilities.
Displays leadership and serves as a positive role model to others in the department.
Level III (in addition to Level I & II essential responsibilities/accountabilities):
Process Management and Documentation -
Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies.
Assists in updated departmental policies, procedures and desk-top manuals relative to the functions
Identifies and develops processes and guidelines for performance improvement opportunities for the Member Care Management Department.
Expert and resource for escalations
Liaison role -
Acts as the liaison point person for activity generated by CAU, CS, PR, Sales & Marketing, CES and Monroe Plan.
Primary liaison between the Member Care Management department and other functional areas.
Mentor (to others in department) - Provides guidance and leadership to the daily activities of the Member Care Management Department clinical staff. Acts as resource to MCM staff, members and providers.
Provides backup for the Supervisor/Manager, whenever necessary. Participates in the orientation of new staff and/training opportunities for all staff. Assists staff to identify opportunities to successfully engage members into care.
Responsible for workflow coordination of the group.
Assists Medical Director (MD) in projects at times.
Responsible for all aspects of the MCM department functions including quality, productivity, utilization performance, ROI and educational needs to address established policies and procedures and job responsibilities.
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
RN with valid and current NYS Nursing Licensure or NYS Licensure in other health care specialty including social work (LCSW/LMSW), respiratory therapy (RT), Registered Dietician (RD) etc. A minimum of three years clinical experience in a health-related field with quality management experience, ambulatory care, community health, behavioral health and/or hospital setting.
Keen business skills - understands business operations in a health plan or health care payor organization
Strong resiliency and flexibility skills
Case Management Certification required within 3 years of employment as care manager - for member care management, only.
Excellent written and verbal communication skills.
Computer experience and use of measurement/criteria.
Strong interpersonal skills.
Must have the ability to travel.
Level II - (in addition to Level I minimum qualifications):
RN with valid and current NYS Nursing Licensure or NYS Licensure in other health care specialty including social work, respiratory therapy, Registered Dietician (RD) etc. A minimum of four year's experience in a health-related field with quality management experience, ambulatory care, community health, behavioral health and/or hospital setting.
Case Management Certification required - for member care management, only.
Must have been in a current Member Care Management position for at least 2 years. If the above is not met, however, transfer to this department either externally or internally should meet all the necessary functions of this level.
Understanding and performing of the Utilizations Management aspects of the job.
Deliver efficient, effective, and seamless care to members.
Understands when to escalate to management.
Be an expert in the technology of the job
Ability to take on broader responsibilities
Ability to participate in training of new staff
Be part of committees and able to lead some committees
Behavioral Health Specific:
Level III - (in addition to Level I & II minimum qualifications):
Must have been in a current Member Care Management position or similar subject expert for at least 5 years
Broad understanding of multiple areas (i.e. UM and MCM). At this level, incumbent is required to know multiple functional areas and supporting systems. (BREADTH)
Expertise in Member Care Management area and able to handle complex assignments, difficult members and highly visible issues. (DEPTH)
Ability to lead the training of new staff.
Demonstrated presentation skills.
The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Excellus Bluecross Blueshield