Description:
GENERAL SUMMARY
Functions as a coordinator of care for members identified as having long-term rehabilitation and/or psychosocial needs as a result of birth defects, chronic conditions, illness or injury for members to prevent exacerbations, re-admissions or need for placement into custodial care. Responsible for implementing and coordinating all case management, psychosocial, and quality of life activities relating to cases across the continuum of care including consultant referrals, home care visits, use of community resources and alternative levels of care. Responsible for developing and carrying out strategies to coordinate and integrate all acute and long-term care services to the members, and to those in case and disease management. Provides psychosocial interventions through resource identification, program development and other means. Interventions will be provided for members in complex caseload as well as to the membership in conjunction with the Utilization Management, Complex Case Management, and Disease Case Management teams. Uses computerbased systems to review medical experience of members and interact with plan staff. This position may specialize within a disease area. Additionally, may serve in a consultative role to other health care professionals.
ESSENTIAL RESPONSIBILITIES
- Responsible for the comprehensive management of members with acute or chronic conditions. Case management activities will focus on quality of care, compliance, outcomes and decreasing costs.
- Responsible for developing and carrying out strategies to coordinate and integrate all acute and long-term care services to members to prevent exacerbations and/or placement of the members in custodial care.
- Performs initial and periodic assessments of the members enrolled in the Long-Term Care Program and/or case or disease management programs.
- Applies case management concepts, principles and strategies in the development of an individualized case plan for enrolled members in case or disease management that are at risk of poor outcomes. The case plan addresses the member’s broad spectrum of needs.
- The case planning process includes the following actions: assessment, goal setting, establishing interventions related to goals, monitoring success of the interventions, evaluating the success of the overall case plan and reporting outcomes.
- Conducts regular discussion and updates with providers, the primary care physicians, health plan Medical Directors, pharmacists, and health services staff regarding the status of particular patients.
- Serves as a member advocate to ensure the member receives all of the necessary care allowed under the member’s benefit plan.
- Understands healthcare reimbursement methods that promote the provision of cost effective healthcare and the preservation of member benefits.
- Utilizes community resource expertise and alternate funding arrangements available to plan members when services are not available under the benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing inpatient lengths of stay, and preventing avoidable Emergency Department utilization.
- Develops relationships with hospital social workers and community resources to assure appropriate care management of catastrophic, acute, and chronically ill members.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- Directs social work interventions including coordinating the distribution, collection, and evaluation of personal health questionnaires to eligible clients, performing psychosocial assessment of the populations, telephone follow-up and in-home or facility assessments as indicated, documentation of problems, assessments, and/or interventions, and promoting ease of access to a continuum of care through appropriate information and referral.
- Indirect services will include meeting federal, state, and NCQA/URAC regulations to assure quality service, working cooperatively with and training other members of the UM team, providing social work consultation to healthcare professionals and members, maintaining an information base of referrals, submitting reports of services provided as directed by department policy, functioning as a liaison person with appropriate community agencies, and determining and implementing policies and procedures with respect to the delivery of social service functions.
- For employees providing disease management for members in the Special Needs Program Model of Care, this role is also responsible for implementing and coordinating case management activities related to the use of community resources and behavioral health issues. Provides psychosocial interventions through resource identification, program development, and other means. May serve in a consultative role to other health care professionals. Assists with securing community resources and will facilitate transportation as appropriate.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Bachelor’s degree in Social Work, Psychology or Gerontology required. Master’s degree preferred. LSW preferred.
- Complies with all state requirements in the state where job duties are performed.
- Minimum (2 years) experience in medical social work or case management. Thorough knowledge of casework and group work principles, practices, and methodology. Extensive knowledge of community resources.
- Considerable knowledge of individual and group behavior and inter-relationships among social, economic, psychological, and physical factors. Considerable knowledge of the regulations, standards, and policies which relate to social work practice.
- Regular local travel 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: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-04-15 00:00:00.0
Job ID: 1311393
GENERAL SUMMARY
Functions as a coordinator of care for members identified as having long-term rehabilitation and/or psychosocial needs as a result of birth defects, chronic conditions, illness or injury for members to prevent exacerbations, re-admissions or need for placement into custodial care. Responsible for implementing and coordinating all case management, psychosocial, and quality of life activities relating to cases across the continuum of care including consultant referrals, home care visits, use of community resources and alternative levels of care. Responsible for developing and carrying out strategies to coordinate and integrate all acute and long-term care services to the members, and to those in case and disease management. Provides psychosocial interventions through resource identification, program development and other means. Interventions will be provided for members in complex caseload as well as to the membership in conjunction with the Utilization Management, Complex Case Management, and Disease Case Management teams. Uses computerbased systems to review medical experience of members and interact with plan staff. This position may specialize within a disease area. Additionally, may serve in a consultative role to other health care professionals.
ESSENTIAL RESPONSIBILITIES
- Responsible for the comprehensive management of members with acute or chronic conditions. Case management activities will focus on quality of care, compliance, outcomes and decreasing costs.
- Responsible for developing and carrying out strategies to coordinate and integrate all acute and long-term care services to members to prevent exacerbations and/or placement of the members in custodial care.
- Performs initial and periodic assessments of the members enrolled in the Long-Term Care Program and/or case or disease management programs.
- Applies case management concepts, principles and strategies in the development of an individualized case plan for enrolled members in case or disease management that are at risk of poor outcomes. The case plan addresses the member’s broad spectrum of needs.
- The case planning process includes the following actions: assessment, goal setting, establishing interventions related to goals, monitoring success of the interventions, evaluating the success of the overall case plan and reporting outcomes.
- Conducts regular discussion and updates with providers, the primary care physicians, health plan Medical Directors, pharmacists, and health services staff regarding the status of particular patients.
- Serves as a member advocate to ensure the member receives all of the necessary care allowed under the member’s benefit plan.
- Understands healthcare reimbursement methods that promote the provision of cost effective healthcare and the preservation of member benefits.
- Utilizes community resource expertise and alternate funding arrangements available to plan members when services are not available under the benefits program.
- Develops new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing inpatient lengths of stay, and preventing avoidable Emergency Department utilization.
- Develops relationships with hospital social workers and community resources to assure appropriate care management of catastrophic, acute, and chronically ill members.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- Directs social work interventions including coordinating the distribution, collection, and evaluation of personal health questionnaires to eligible clients, performing psychosocial assessment of the populations, telephone follow-up and in-home or facility assessments as indicated, documentation of problems, assessments, and/or interventions, and promoting ease of access to a continuum of care through appropriate information and referral.
- Indirect services will include meeting federal, state, and NCQA/URAC regulations to assure quality service, working cooperatively with and training other members of the UM team, providing social work consultation to healthcare professionals and members, maintaining an information base of referrals, submitting reports of services provided as directed by department policy, functioning as a liaison person with appropriate community agencies, and determining and implementing policies and procedures with respect to the delivery of social service functions.
- For employees providing disease management for members in the Special Needs Program Model of Care, this role is also responsible for implementing and coordinating case management activities related to the use of community resources and behavioral health issues. Provides psychosocial interventions through resource identification, program development, and other means. May serve in a consultative role to other health care professionals. Assists with securing community resources and will facilitate transportation as appropriate.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Bachelor’s degree in Social Work, Psychology or Gerontology required. Master’s degree preferred. LSW preferred.
- Complies with all state requirements in the state where job duties are performed.
- Minimum (2 years) experience in medical social work or case management. Thorough knowledge of casework and group work principles, practices, and methodology. Extensive knowledge of community resources.
- Considerable knowledge of individual and group behavior and inter-relationships among social, economic, psychological, and physical factors. Considerable knowledge of the regulations, standards, and policies which relate to social work practice.
- Regular local travel 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: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-04-15 00:00:00.0
Job ID: 1311393