Job Description

The Medical Case Manager manages and tracks all members who require a comprehensive approach to immediate and ongoing care of their complicated and/or catastrophic illnesses. This position also coordinates care for all members experiencing a care transition from one level of care back to their residence. The Medical Case Manager documents interactions with and on behalf of the member throughout service delivery including, but not limited to: care plans, progress notes, assessments, correspondence, and authorizations.

Provide Care Coordination and Case Management services:

  • Act as a liaison to facilities, providers and/or members related to issues in case management and care services
  • Identify member needs and address these needs to remove any barriers in achieving optimal behavioral health and medical care
  • Educate members on the importance of good health and following up with the Primary Care Physician on a regular basis
  • Complete member surveys, assessments and care plans
  • Request and review medical records
  • Provide and coordinate community resources and referrals
  • Provide member education on disease processes
  • Collaborate with the Interdisciplinary Team to incorporate best practices, assess outcomes and develop individualized care plans
  • Develop and monitor the member’s care plan goals for progress and outcomes
  • Accurately document members’ case management plans, authorizations, assessment, and levels of care
  • Attend case management team meetings, as scheduled
  • Other duties as assigned

Identify members who had a recent transition of care and assist with follow up and discharge needs:

  • Identify members through various reports who have specific disease conditions, such as, Diabetes, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Asthma
  • Complete the Transition of Care survey with members
  • Coordinate with all providers involved in the treatment of members identified as needing assistance with managing chronic medical conditions
  • Assess member’s medical, social, environmental and functional needs and address identified needs with the member’s medical team and develop a comprehensive treatment plan
  • Notify the member’s Primary Care Physician of admission and discharge from any inpatient setting to facilitate coordination of care
  • Monitor members for thirty (30) days post-discharge to ensure medical needs are met and to decrease readmission
  • Monitor progress towards treatment goals

Monitor members identified through the High Utilization of ER Services Reports, Member Profile Report, Disabled Report:

  • Assist members in obtaining routine medical care through their assigned Primary Care Physician (PCP)
  • Identify barriers in obtaining outpatient services outside of an ER
  • Assist members and providers in developing a care plan which addresses member needs
  • Educate members and providers on services available to address chronic disease, chronic illness management or other identified reasons for utilization of the ER
  • Assist members with provider referrals, appointments and transportation, as needed
  • Refer members to case management if the member is in need of ongoing case management services

Education:

  • Active, current, valid, unrestricted Utah State Registered Nurse or LCSW License required

Years of Experience:

  • Minimum of two (2) years of experience in a healthcare setting
  • HMO/Managed Care/ Medicare/Medicaid experience preferred

Specialized Knowledge:

Case Management/Disease Management experience preferred

Application Instructions

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