Case Manager Hfhp - Clinical Integration Services

POSITION SUMMARY:

To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by: identifying members with complex medical needs and coordinating their care. This is accomplished by completing a thorough assessment, developing a proper Plan of Care, implementing, monitoring and modifying the Plan of Care as needed, and determining clinical and financial outcomes. The Case Manager promotes and evaluates the effective utilization of resources using current clinical knowledge, awareness of community resources/services and functioning as a member advocate to ensure optimal case outcomes.

PRIMARY ACCOUNTABILITIES:

Quality/No Harm:

• Performs reviews to assure members are receiving care in the appropriate setting at the appropriate level.

• Collaborates with members of the healthcare team to facilitate continuity of care, care plans, discharge planning and/or transition of care.

• Collaborates with Medical Director regarding issues of medical necessity, benefit coverage and availability of services.

• Updates authorizations with accuracy and completeness to support accurate claim payments and collaborates with Utilization Management team to assure appropriate care.

• All case management activity to be performed throughout the continuum of care from case referral to case closure and will involve direct member contact.

• Complete a thorough assessment that collects in-depth information about a member's unique situation and functioning in order to identify individual needs. Information gathered should include direct client contact information and all other relevant sources. Based on identified needs, develop a comprehensive case management plan.

• Conduct thorough planning to include determining and documenting specific objectives, goals and actions all designed to meet the member's identified needs. Plans should be time-specific and action oriented.

• Implement plans by executing and documenting specific interventions, activities and/or tasks that will lead to accomplishing the established goals.

• Organize, establish, integrate, update, modify and document resources necessary to accomplish the goals established in the case management plan.

• Continue to gather information from all relevant sources and documentation and determine the plans effectiveness.

• Evaluate the plan at appropriate intervals to determine the case management plan's effectiveness in reaching the goals and outcomes. Modify the plan as necessary.

• Determine outcomes by measuring the interventions in order to determine the effectiveness of performing case management. Areas to be measured to include clinical, financial, variance, quality, quality of life and client satisfaction.

• All case management activities to maintain a member's confidentiality and privacy, ensuring member safety, adherence to advocacy ethics as well as legal and accreditation/regulatory standards.

Stewardship:

• Utilizes Health First Health Plan resources in a cost effective manner.

• Document member cost savings based on appropriate utilization of services and evidence based care.

• Identify and document alternative cost saving options for members.

QUALIFICATIONS REQUIRED:

• Current Florida RN license free of any restrictions or disciplinary action pending and able to legally and independently practice without the supervision of another licensed professional.

• Five years clinical experience.

• Knowledge of CPT codes, HEDIS, HIPAA, ICD-9 codes, Medicare Guidelines, and NCQA.

• Knowledge of Coordination of Benefits where applicable (i.e., Workers Compensation, Auto Insurance, Short and Long Term Disability).

• Knowledge of Billing and Claims processing.

• Knowledge of appropriate referrals to Ethics Committee, Corporate Compliance, Fraud and Abuse or Legal Services when appropriate.

• Knowledge of Reimbursement across the continuum of healthcare to propose alternative treatment options.

• Knowledge of alternative treatments options, alternative funding programs and community services and resources.

QUALIFICATIONS PREFERRED:

• Bachelors Degree in Nursing.

• Two years previous experience to include Utilization Management, Managed Care, and/or Workers Compensation/Disability Medical Management.

• Certified Case Manager (CCM).

Case Management Concepts

• Case Management practice and methods used to establish quality measures and practice parameters. This is to include knowledge of accreditation standards and requirements, Case Management Departmental Model, Case Management Process and available tools. Appropriate case documentation to include goals, objectives and outcomes. Participate in departmental program evaluation, satisfaction survey distribution and evaluation, quality improvement initiatives and performance improvement measures.

Case Management Principles and Strategies

• Case Managers are to maintain member's confidentiality and ethics including those pertaining to advocacy, experimental treatment/protocols, end of life, refusal to treatment/services and benefit limits. In order to achieve the above, the Case Manager will effectively utilize conflict resolution strategies and negotiations. Member's safety is to be monitored throughout the case duration in order to identify, address and resolve potential or actual risky situations. Case Managers are to adhere to the Case Management Standards of Practice.

Psychosocial and Support Systems

• Case Managers are to incorporate into their plans specific interventions that address family and cultural issues. Case Management Assessments, Interventions and Plans to include the following when applicable:

• Behavioral health and psychiatric disability issues.

• Psychological and neuropsychological issues.

• Substance abuse.

• Addiction.

• Wellness and illness prevention.

• Multicultural issues.

• Chronic illness and disability aspects.

• Spirituality as it relates to their health.

• Complementary alternative medicine management.

• Members in various stages of crisis (emotionally, psychologically, physically, financially).

• Community resources and support groups should be identified and referrals made.

Healthcare Management and Delivery

• Case Managers are to have the knowledge and expertise to manage their members across all healthcare settings throughout the continuum of care. Assessment and management of members to include:

• Acute and chronic illness and disability.

• Physical functioning.

• Assistive technology.

• Medication management while functioning within the parameters of clinical pathways.

• Standards of care or practice guidelines.

• Other healthcare settings/providers could include rehabilitation service providers, vendors, community resources, case managers from other settings and other healthcare delivery entities.

Healthcare Reimbursement

• Cost containment principles should be adhered to resulting in case cost savings analysis produced.

• Case Managers are to be familiar with the following funding sources:

• Managed care.

• Prospective payment systems.

• Private benefit programs (e.g., pharmacy benefit programs).

• Public benefit programs (e.g., SSI, SSDI, Medicare, Medicaid).

• Utilization Management.

PHYSICAL DEMANDS:

• Must be able to sit or stand minimum of eight hours per day using telephone and computer.

• Ability to effectively communicate with all members of the health care team, members, families and fellow staff members.

• Ability to work extended hours to see issues through to resolution.

MENTAL DEMANDS:

• Handle stressful and dynamic work situations.

• Ability to work with all types of members despite age, ethnicity, medical or mental impairment, disabled or those emotionally upset with the Health Plan.

• Ability to handle multiple tasks, often within time constraints.

• Must be flexible, reliable and a person of good moral character.