Job Description:
• Provide telephonic case management between providers, patients and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants
• Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs
• Use claims processing tools to review and research paid claim data to develop a clinical picture of a member’s health and identify for participation in appropriate programs
• Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals
• Monitor interventions and evaluate the effectiveness of the treatment plan in a timely manner; report measurable outcomes that record effectiveness of interventions
• Initiate and maintain contact with the patient/family, provider, employer, and multidisciplinary team as needed throughout the continuum of care
• Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance
• Be able to meet productivity, quality and turnaround time requirements on a daily, weekly and monthly basis
• Negotiate and implement cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews and cost avoidance reports
• Establish and maintain working relationships with healthcare providers, client/group, and patients to provide emotional support, guidance and information
• Evaluate and make referrals for wellness programs
• Maintain complete and detailed documentation of case managed patients in Eldorado and UM Web; maintain site specific files ensuring confidentiality; prepare reports and updates at 30-day intervals for high-risk cases and 90 days interval for low-risk cases ensuring confidentiality according to Company policy and HIPAA
• Perform Utilization Review for assigned members.
• Serve as mentors to LVNs and provide guidance on complicated cases as it relates to clinical issues
Requirements:
• Graduation from an accredited Registered Nursing (RN) program
• Possession of a current California RN license; a multi-state license will also be required
• Minimum of five (5) years medical/surgical or acute care experience, including two years’ experience in case management, or an equivalent combination of education and experience
• Prior case management experience, emergency room, critical care background or other relevant clinical care experience pertinent to case management
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Ability to critically evaluate claims data and determine treatment plan, discharge planning experience
• Ability to work independently making decisions and problem solving
• Knowledge of community resources and alternate funding programs
• Computer proficiency or working knowledge of Microsoft Office Suite
• Excellent interpersonal, communication and negotiation skills
• Strong customer orientation
• Good time management skills and highly organized.
Benefits:
• Part-time schedule designed around your availability and life priorities
• Access to learning and development opportunities alongside full-time colleagues
• Mentorship and skill-building that translates to career advancement
• Competitive hourly compensation that values your expertise
• Technology and equipment support to set you up for success