SUMMARY: Case Management is the collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes. Nurses are responsible for the identification, evaluation and coordination of all health care services provided to a select managed care population to manage the continuum of care, provide relevant and measurable outcomes to the ACM manager, administration, Management Committees and contracted Health Plans.
DEFINITION: Ambulatory Case Management is defined as MHC established case management programs that assist in the delivery of quality care to enrolled patients. They include, but are not limited to, Complex and High Risk Management, Transplant Management, Pediatric Management and High Risk Pregnancy Management
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Identifies and evaluates members for enrollment into one of the Monarch HealthCare ACM programs through the following mechanisms:
a) Physician referral
b) High-risk screening tools
c) Ambulatory utilization
d) Inpatient concurrent review (acute/sub-acute)
e) Diagnosis screening criteria
f) Family Member/significant other referral
g) Internal data analysis
2. Assesses, plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the member's health status.
3. Integrates evidence-based clinical treatment guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans.
4. Develops treatment plans that are patient-centered, promoting efficiency and quality in the delivery of healthcare for the designated patient population
5. Develops systems of care that monitor member progress and promote early intervention in acute care situations
6. Works effectively with other members of the health team to optimize interventions; coordinating health care services with appropriate physicians, facilities, contracted providers, and ancillary providers; acting as liaison between member, HealthCare Team, and MHC Medical Director
7. Manages utilization and practice metrics to further refine the delivery of care model to maximize quality, clinical, and fiscal outcomes for the designated patient population
8. Reviews all referrals and authorizations associated with assigned cases in accordance with MHC and NCQA Standards.
9. Coordinates out-of-network and out-of-area cases with member, Health Plans and HealthCare Team; provides alternative health care services utilizing contracted and community services/programs.
10. Collects and analyzes health services data, including emergency care utilization, for the purpose of monitoring, tracking, trending, and physician/member education
11. Refers members to appropriate health plan, State or Federal Disease/Condition Management programs.
12. Acts as resource for department staff, inter-departmental staff, contracted physicians, Health Plans, contracted facilities, members/families and ancillary providers.
13. Maintains comprehensive and confidential patient case files
14. Maintains confidentiality of all member information and MHC business as per HIPAA regulations
15. Attends/coordinates Patient Care Conferences, on and off-site as necessary.
16. Provides any/all MHC Committees with comprehensive summary of all active ACM cases as required.
17. Assists with the evaluation and revision of CM policy and procedures.
18. Presents as a professional representative of Monarch HealthCare.
19. Performs additional duties/tasks as assigned by the Supervisor and/or Manager.
20. Maintains and complies with all Monarch HealthCare policy and procedures.
21. Regular and consistent attendance
What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work with in an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you'll open doors for yourself that simply do not exist in any other organization, anywhere.
Assist with the supervision of the Case Management Care Coordinator relating to daily workflow, program operations, and processes.
To perform this job successfully, an individual must be able to perform each essential duty. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE:
* Graduate of an accredited School of Nursing.
* BSN or equivalent desirable.
* Minimum of 3 years recent acute care or managed care experience.
* Minimum of 3 years recent care/case management experience.
* Use of Community resources in care management.
* Knowledge and use of State and Federal programs as resource in case management.
* Current and valid, unrestricted California state nursing license.
* CCM preferred.
SKILLS AND ABILITES:
* Demonstrated ability to work autonomously and to be directly accountable for practice
* Demonstrated ability to influence and negotiate individual and group decision-making
* Demonstrated ability to operate effectively in a dynamic, fluctuating, and rapidly changing environment
* Demonstrates customer-focused interpersonal skills to interact in an effective manner with the interdisciplinary health care team, practitioners, community agencies, patients and families, with respect to the diverse opinions, values, religious beliefs, and cultural ideals that will be encountered
* Demonstrates leadership qualities including: time management, verbal communication, written communication, listening skills, problem solving, decision-making, priority setting, work delegation and work organization
* Good to excellent computer skills.
* Self-motivated, proactive team member with effective critical thinking skills.
* Ability to work collaboratively as part of the Case Management department team and all other areas providing member services or support.
* Thorough knowledge of managed care, third party payers, regulatory requirements and government entitlement programs.
* Excellent telephonic etiquette.
* Analyze, and interpret job related scientific and technical journals, financial and data reports and legal documents.
* Respond effectively verbally and in writing to inquiries or complaints from customers, regulatory agencies or members of the business community.
* Communicate assertively as well as collaboratively with Management, staff, health plans, physicians, and patients.
* Effectively present information to management team.
* Bi-lingual desirable.
* Apply concepts such as fractions, percentages, ratios and proportions to practical situations.
* Read and interpret daily department reports that include raw data, trends displayed in graphs.
* Explain, share and use this data with all staff members.
* Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
* Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
* Ability to set priorities, define and implement effective workflow and processes.
CERTIFICATES, LICENSES, REGISTRATIONS:
* Current and valid, unrestricted, California Registered Nursing (RN) license, or License Vocational Nurse (LVN) license.
* Current Certified Case Man
Skills / Requirements