Medical Case Manager
1 week ago
About the Position:
PacificSource is seeking a skilled Medical Case Manager to join our healthcare services department. As a key member of our team, you will play a vital role in ensuring our members receive high-quality, cost-effective care.
About the Role:
In this role, you will work closely with physicians, nurses, social workers, and other medical and non-medical professionals to coordinate delivery of healthcare services. You will assess members' specific health plan benefits and available resources, providing utilization management services that promote quality outcomes and responsible healthcare spending.
Key Responsibilities:
- Assess member information to promote wellness, appropriate utilization, and cost-effective care.
- Coordinate necessary resources to achieve member outcome goals and objectives.
- Accurately document case notes and letters of explanation for legal records.
- Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.
- Maintain contact with inpatient facility utilization review personnel to ensure appropriateness of continued stay and level of care.
- Identify cases requiring discharge planning, including transfers to skilled nursing facilities, rehabilitation centers, residential, and outpatient services.
- Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.
- Negotiate with vendors to provide services and negotiate discounts with non-contracted providers.
- Work with multidisciplinary teams using an integrated approach to best support members.
- Serve as primary resource for member questions and concerns related to the health plan and navigating health systems issues.
Requirements:
- Minimum three years of nursing or behavioral health experience with varied medical and/or behavioral health exposure required.
- Experience in acute care, case management, and rehabilitation, home health, and hospice treatment strongly preferred.
- Registered Nurse or clinically licensed behavioral health practitioner with current unrestricted state license required.
- Case Manager Certification as accredited by CCMC preferred.
Estimated Salary: $72,000 - $100,000 per year, depending on experience.
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