Medical Case Manager
3 weeks ago
Job Summary
This role ensures that members with complex medical and/or psychosocial needs have access to high-quality, cost-effective healthcare. The successful candidate will assist in the holistic assessment, planning, arranging, coordinating, monitoring, and evaluation of outcomes and activities necessary to facilitate member access to healthcare services. They will advocate for the most appropriate care plan using sound clinical judgment, accurate planning, and collaboration with internal and/or external customers and contacts. The role requires following established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member's care and progress across the continuum of care.
Key Responsibilities
- Communicate effectively with customers and external contacts through telephonic interviewing and communication.
- Interact with Case Management Specialists, Management Team, Physician Advisors, and other interdepartmental contacts to ensure seamless coordination of care.
- Maintain knowledge of medical terminology and medical diagnostic categories/disease states to provide informed care.
- Educate members to enhance their understanding of illness/disease impact and promote positive outcomes.
- Collaborate with Primary Care Physicians, Medical Specialists, Home Health, and other ancillary healthcare providers to coordinate member care.
- Collect member medical information from various sources, including providers and internal records, and use clinical judgment to determine unmet member needs.
- Work independently to identify, define, and resolve a variety of problems experienced by members.
- Develop individualized plans of care tailored to meet the specific needs of each member.
- Anticipate member needs by continually assessing and monitoring progress toward goals, care plan status, and adjusting goals as necessary.
- Maintain a working knowledge of available resources to address identified member needs and facilitate proactive and efficient provision of services.
- Consider benefit design and cost-benefit analysis when planning interventions to develop realistic care plans.
- Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
- Maintain a working knowledge of community resources available to assist members.
- Coordinate with community organizations/agencies to identify additional resources for which the MCO is not responsible.
- Work within a team environment to achieve shared goals.
- Attend and participate in required meetings, including staff meetings, internal rounds, and other in-services, to enhance professional knowledge and competency.
- Participate in departmental and/or organizational work and quality initiative teams.
- Collaborate with peers, Case Management Specialists, Management Team, Physician Advisors, and other interdepartmental contacts.
- Participate in interagency and/or interdisciplinary team meetings when necessary to facilitate coordination of member care and resources.
- Foster effective work relationships through conflict resolution and constructive feedback skills.
- Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.
- Educate health team colleagues about the role and responsibility of Case Management and the unique needs of the populations served.
Qualifications
Minimum
- Bachelor's degree in nursing or RN certification in lieu of bachelor's degree or Master's degree in Social Work and 3 years of experience in Acute or Managed Care/ experience with Medicaid or Medicare populations. OR
- Bachelor's degree in Social Work with 5 years of experience in Acute or Managed Care/ experience with Medicaid or Medicare populations
Preferred
- Experience working with high-risk pregnant women OR experience working with chronic condition adult populations OR experience with pediatrics
- 3-5 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
- Bilingual English/Spanish language skills.
- Case Management Certification
Licenses and Certifications
Required
- Licensed Social Worker (LSW)-Non-Specific - State (OR) Registered Nurse - Non-Specific
Skills
- None
Scope of Responsibility
Does this role supervise/manage other employees?
No
Work Environment
Is Travel Required?
No
Pay Range Minimum:
$57,700.00
Pay Range Maximum:
$106,700.00
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ()
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