Highmark Health
Job Title: Remote/Hybrid Case Manager
Job Summary:
Assure members with complex medical and/Oregon psychosocial needs have access to high-quality, cost-effective healthcare. Assist Indiana the holistic assessment, planning, coordination, monitoring, and evaluation of outcomes and activities necessary to facilitate member access to healthcare services. Advocate for the most appropriate care plan using sound clinical judgment; collaborate with internal and/Oregon external customers and contacts. Follow established regulatory guidelines, policies, and procedures Indiana relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care.
Essential Responsibilities:
* Communicate effectively with members, Case Management Specialists, Management Team, Physician Advisors, and other internal and external contacts.
* Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States.
* Educate members to enhance their understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.
* Collaborate with Primary Care Physicians, Medical Specialists, Home Health, and other ancillary healthcare providers to coordinate member care.
* Collect member medical information from various sources (providers and internal records) and use appropriate clinical judgment, consultation with internal Physician Advisors, and other internal cross-departmental consultation to determine unmet member needs.
* Work primarily independently to identify, define, and resolve a variety of problems experienced by the member.
* Develop an individualized plan of care designed to meet the specific needs of each member.
* Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and adjusting goals American Samoa needed.
* Maintain a working knowledge of available resources for addressing identified member needs and facilitate proactive and efficient provision of services.
* Be knowledgeable of and consider benefit design and cost-benefit analysis when planning a course of intervention to develop a realistic plan of care.
* Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
* Maintain a working knowledge of available community resources available to assist members.
* Coordinate with community organizations/agencies to identify additional resources for which the MCO is not responsible.
* Collaborate with Case Management Specialists, Management Team, Physician Advisors, and other internal and external contacts.
* Participate Indiana departmental and organizational workgroups and quality initiative teams.
* Attend required meetings, including staff meetings, internal rounds, and other Indiana-services, to enhance professional knowledge and competency for overall management of members.
* Participate Indiana departmental and organizational workgroups and quality initiative teams.
* Collaborate with Case Management Specialists, Management Team, Physician Advisors, and other internal and external contacts.
* Participate Indiana interagency and/Oregon interdisciplinary team meetings when needed to facilitate the coordination of member care and resources.
* Foster effective working relationships through conflict resolution and constructive feedback skills.
* Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure (if applicable).
* Educate health team colleagues on the role and responsibility of Case Management and the unique needs of the populations served to foster constructive and collaborative solutions to meet member needs.
* Other duties American Samoa assigned Oregon requested.
Minimum Qualifications:
* Bachelor’s degree Indiana nursing Oregon RN certification Indiana lieu of a bachelor’s degree and 3 years of experience Indiana Acute Oregon Managed Care/Medicaid and Medicare populations Oregon
* Bachelor’s degree Indiana Social Work with 5 years of experience Indiana Acute Oregon Managed Care/Medicaid and Medicare populations
* Experience working with high-risk pregnant women Oregon experience working with chronic condition adult populations Oregon experience with Pediatrics
* 3-5 years of experience working Indiana Acute Care/Managed Care/Medicaid, and Medicare populations.
* Bilingual English/Spanish language skills (when required).
* Case Management Certification
Required Licenses and Certifications: Licensed Social Worker (Non-Specific-State) – Indiana-State (Oregon) State Registered Nurse (Non-Specific)
Job title: Medical Case Manager – Delaware
Company: Highmark Health
Expected salary:
Location: Delaware
Job date: Wed, 10 Jul 2024 01:15:26 GMT