The Disease Management Specialist is responsible for the assessment, planning, implementation, coordination, monitoring and evaluation of the case management plan of care across the continuum of care for the member, family or legal representative. This process includes negotiations, providing assistance and the coordination of the necessary services and resources to meet the member's care needs while facilitating quality clinical and cost outcomes.
The Disease Management Specialist job duties also include, but are not limited to:
Applies Disease Management principles to guide members along the continuum of care to the optimal functional level and quality of life through the utilization of available resources to achieve the most favorable clinical and cost outcomes.
Employs clinical knowledge, critical thinking, decision-making and problem-solving skills to develop a holistic customized goal-orientated disease management plan of care for moderate disease management cases. Identifies and resolves barriers to adherence to the DM plan of care.
Coordinates services necessary to implement to the DM plan of care and utilizes available benefits and resources judiciously to achieve quality and cost effective outcomes.
Promptly closes cases and ensures prompt closure by team according to SWHP case closure criteria. DM staff will transitions member to most appropriate continuum of care setting/program, evaluate impact of DM interventions on the achievement of goals, and will completes required reports.
Seeks out and participates in continuing education offerings to maintain current knowledge and in disease management trends and best practices.
Collaborates with member, family, significant other(s), and physician's to develop a customized DM plan of care with mutually established long term and short-term goals. Provides sufficient information to the member, family, significant other(s) to facilitate informed decisions and choices. Advocates for the member and works collaboratively with the interdisciplinary health care team to coordinate quality and cost effective services to meet the member's care needs and established goals.
Manages caseloads of 100-150:1 medium priority cases with a small volume of high priority cases within established quality, production, and timeliness standards.
Identifies gaps and opportunities for process improvement, program development and amendments and makes recommendations to Manager or Director. Complies with all federal, state, and SWHP confidentiality requirements without exception;
Participates in quality improvement initiatives initiated by SWHP or as required by accreditation organizations.
At CMOs discretion, Disease management staff may be asked to focus on specific targeted populations for example, such as members seeking out of network care, selected high-risk members, members with emergency room overuse.
The ideal candidate for the Disease Specialist role will possess knowledge of product lines, contracts, networks, internal and external resources, etc., and will be a self-starter with the ability to work independently with minimal supervision or equally well within a team environment.
Scott & White Health Plan
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Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation's exemplary health care organizations. Founded as a Christian ministry of healing, the mission of Baylor Scott & White Health is to promote the well-being of all individuals, families and communities. Joining our team is not just accepting a job, it's accepting a calling!
H.S. Diploma/GED Equivalent
4+ years experience required
License Vocational Nurse
Baylor Scott & White Health