Medical Case Manager - RN - SHCN
Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
This position is responsible for the management and tracking of all members which require a comprehensive approach to immediate and ongoing care of their complicated and/or catastrophic illnesses.
Accepts members into case management from the Prior authorization and utilization review staff, facility referrals, HCA member survey (high risk indicators), and member PCP.
* Acts as a liaison with the utilization review specialist to facilitate transition from acute care settings to least restrictive environments.
* Coordinate Hep C treatment plan with Specialist and pharmacy and ensure members receive their delivery of specialty medication.
* Coordinate Transplant services with Specialists - HemOnc, GI and Nephrology etc.
* Develop working relationships with Transplant Centers.
* Assists physicians with placement of members into an appropriate level of care, or community services.
* Acts as a liaison to facilities, providers and or members related to issues in case management, care services.
* Responsible for the initiation, identification of members for Disease Management programs as set in QM/PI plan.
* Ensures confidentiality of member information.
* Participates with QM/PI plan improving performance in order to impact the overall quality of clinical and support process. Meeting AHCCCS requirements within contract.
Attends and participates ongoing education and staff meetings.
Based upon available information, authorization member plan of care, in coordination with PCP orders, or other ancillary services. Appropriately documentation for level of care.
* Consistent and clean documentation within MedMC of members case management plan, authorizations, and levels of care.
* Documentation accurately information regarding patient assessment and treatment plan.
* Ensure tracking system is in place for Hep C, HIV and Transplant.
* Ensure AHCCCS required reporting such as the Transplant log is maintained and forwarded to AHCCCS with mandated timeframes.
* Actively participates in the OFR and CMS audit.
* Attends weekly case management team meetings
* Reviews all denials with Medical Director(s) for determination.
* Responsible for proactive role in management of utilization and control of non-medically necessary services.
* Responsible for discharge planning from case management and clean documentation of such.
* Reports timely to Case Management Supervisor of cost savings, with documentation to confirm.
Accepts patients into case management: act as a liaison with the utilization review nurses, assist physicians with placement of patients into an appropriate level of care, monitors and assess levels of care, appropriateness of length of stay, and quality of care, act as a liaison to hospitals, facilities, physicians and members on issues related to case management
Authorize patient care services in coordination with physicians and/or other ancillary services: attend member care conferences for patients in non-hospital settings, attend weekly case management rounds with Sr. Director of Medical Services, Case Management Coordinator and Medical Director(s), Responsible for taking a proactive role in the management of utilization and control of non-medially necessary services responsible for case management, and discharge planning of HCA members.
Knowledge: HMO/Managed Care, Medicare experience preferred
Previous case management experience 2 years.
Basic computer skills, strong written and verbal communication skills necessary.
Medical review knowledge a plus, Interqual, Milliman USA
Reliable transportation with current AZ. Coverage required.
Minimum of 3-4 years acute care experience required
At least 2 years of transplant experience
Medicare, Medicaid experience preferred
Interqual experience is required
Specific Certifications or Licenses:
Arizona R.N. License required