Description:
NEW OPPORTUNITY - COMPLEX CASE MANAGERCo-Morbid Case Management (CMCM) is an Enhanced Care Management Program focusing on high risk, co-morbid aged; blind and disabled Medicaid members utilizing face to face nurse case manager visits integrated with a MultiDisciplinary Team (MDT) and the member's primary care physician in an effort to enhance care quality and reduce medical utilization.This is a work from home opportunity in Kentucky Medicaid Region 8.The ESSENTIAL RESPONSIBILITIES for the CMCM Complex Case Manager are:
- Comprehensive management of members with a Co-Morbid illness.
- Proactive management with the objective of improving quality outcomes and decreasing costs.
- Early identification and assessment of members for admittance to a comprehensive case management program.
- Apply case management concepts; principles; and strategies in the development of an individualized case plan that addresses the member's broad spectrum of needs. The case planning process includes the following actions: initial home visit; assessment; goal setting; establishing interventions related to goals; monitoring success of the interventions; evaluating the success of the overall case plan; and reporting outcomes.
- Interviews members telephonically; in the physician's office; home visits or in other facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the member's primary care physicians; other providers including behavioral health providers; health plan Medical Directors; health services staff and to MultiDisciplinary Team.
- Serves as the member's advocate to ensure they receive all necessary care allowed under their benefit plan. Develop knowledge of community resources and alternate funding arrangements available to the member; when services are not available under their benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing their lengths of stay.
- Develops relationships with hospital social workers and community resources to assure appropriate management of catastrophic and chronically ill members.
- Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective healthcare and the preservation of the member.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- May serve as a consultant to the physician network(s) to insure overall improvement in quality of medical care and outcomes.
- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management; case management; and general medical issues.
- Maintains confidentiality of member's information in accordance with HIPPA regulations.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active Kentucky state license.
- Bachelor's degree or equivalent experience preferred.
- Complies with all state certification requirements in the state where job duties are performed.
- Previous experience (usually 1+ year) in case management.
- Significant experience (usually 3+ years) clinical experience.
- Utilization management experience and knowledge of community resources preferred.
- Experience with using computer systems as part of the clinical activity.
- Regular local travel may be required.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Hazard, KY, US
Other Locations: Pikeville-Kentucky-United States,
Organization: 10900 - CMS - STAR Corporate
Schedule: Full-time
Job Posting: 2013-08-29 00:00:00.0
Job ID: 1312869
NEW OPPORTUNITY - COMPLEX CASE MANAGERCo-Morbid Case Management (CMCM) is an Enhanced Care Management Program focusing on high risk, co-morbid aged; blind and disabled Medicaid members utilizing face to face nurse case manager visits integrated with a MultiDisciplinary Team (MDT) and the member's primary care physician in an effort to enhance care quality and reduce medical utilization.This is a work from home opportunity in Kentucky Medicaid Region 8.The ESSENTIAL RESPONSIBILITIES for the CMCM Complex Case Manager are:
- Comprehensive management of members with a Co-Morbid illness.
- Proactive management with the objective of improving quality outcomes and decreasing costs.
- Early identification and assessment of members for admittance to a comprehensive case management program.
- Apply case management concepts; principles; and strategies in the development of an individualized case plan that addresses the member's broad spectrum of needs. The case planning process includes the following actions: initial home visit; assessment; goal setting; establishing interventions related to goals; monitoring success of the interventions; evaluating the success of the overall case plan; and reporting outcomes.
- Interviews members telephonically; in the physician's office; home visits or in other facilities to provide initial and ongoing case management services.
- Conducts regular discussions and updates with the member's primary care physicians; other providers including behavioral health providers; health plan Medical Directors; health services staff and to MultiDisciplinary Team.
- Serves as the member's advocate to ensure they receive all necessary care allowed under their benefit plan. Develop knowledge of community resources and alternate funding arrangements available to the member; when services are not available under their benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing their lengths of stay.
- Develops relationships with hospital social workers and community resources to assure appropriate management of catastrophic and chronically ill members.
- Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective healthcare and the preservation of the member.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- May serve as a consultant to the physician network(s) to insure overall improvement in quality of medical care and outcomes.
- May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management; case management; and general medical issues.
- Maintains confidentiality of member's information in accordance with HIPPA regulations.
Qualifications:
JOB SPECIFICATIONS
- Registered nurse with active Kentucky state license.
- Bachelor's degree or equivalent experience preferred.
- Complies with all state certification requirements in the state where job duties are performed.
- Previous experience (usually 1+ year) in case management.
- Significant experience (usually 3+ years) clinical experience.
- Utilization management experience and knowledge of community resources preferred.
- Experience with using computer systems as part of the clinical activity.
- Regular local travel may be required.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Hazard, KY, US
Other Locations: Pikeville-Kentucky-United States,
Organization: 10900 - CMS - STAR Corporate
Schedule: Full-time
Job Posting: 2013-08-29 00:00:00.0
Job ID: 1312869