Case Manager

4 weeks ago

Kapolei, United States HMSA Full time
  1. Engagement, Assessment and Planning
    • Engages members in the case management program (outreach and successful enrollment) using diagnostic cost group classifications or other tools which identify the relative risk score and illness burden. Identifying catastrophic health care users with significant health care costs is a priority.
    • Conducts and documents a comprehensive assessment of the member's health and psych/social needs, including health literacy and social determinants of health. Gathers clinical information which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include: available support systems, available benefits, community resources, financial, transportation, employment, housing, educational, and health information as appropriate to develop and create an effective care plan and medication compliance.
    • Utilizes case-management clinical knowledge and experience to coordinate integrated care-plan in collaboration with Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition.
    • Assist with transition of care to ensure continuity of care
    • Determines need for and coordinates inter-disciplinary and/or family conferences.
    • Conducts face to face visits to member's homes, facility, community settings, PCP office or virtually.
  2. Implementation / Evaluation
    • Analyzes situations and determine proper course of action by making critical decisions and utilizing independent clinical judgment.
    • Proactively identifies member care needs and develops and communicates a collaborative Plan of Care. Ensures member is progressing towards desired outcomes by monitoring care through ongoing assessments and/or member records. Identifies and provide educational and community resources, support groups, medication review, pharmacy program and financial assistance and alternative payers (COBRA, SSDI etc.). Assists with planning and coordination including out of state services, follow-up appointment with treating physician, and assists with self-management of serious or complex conditions.
    • Communicates with providers and develops collaborative relationships.
    • Interacts with the member as needed and necessary via telephone and face-to-face visits and provides support until the member and their authorized representative can manage and maintain the health of the member.
    • Documents the necessary communication and timely follow up with the member, family, physicians, and other health care providers to ensure the member's progression in meeting the established care plan goals.
    • Evaluates ongoing management of plan of care.
    • Evaluates member and provider satisfaction and quality of care provided.
  3. Miscellaneous Support
    • Participates in the preparation and on-site reviews for Employer/Group accreditation audits.
    • Responsible for completion of documentation review and self-audit as assigned by management.
    • Assists in claims inquiries and resolution.
    • Participates in meetings with Providers and or Provider group leaders to improve quality and effectiveness of services provided to members.
  4. Performs all other miscellaneous responsibilities and duties as assigned or directed

#LI-Hybrid

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