To participate in the case management process, acting as a patient advocate, seeking and coordinating solutions to the health care needs of members. The case manager develops a case management plan with long and short-term goals and coordinates inter-disciplinary services providing members with quality services to meet established goals.
Develops a case management plan based on an assessment of the member’s clinical and psychosocial status.
Acts as a liaison between members and providers.
Assists members in obtaining routine and/or complex medical care.
Ensures that each member’s privacy is protected during the process of coordinating care services, consistent with confidentiality requirements in 45 CFR parts 160 and 164, specifically regarding the privacy of individually identifiable health information.
Documents enrollment of the member in the case management program in the case management module of the Fortuna System. Documents all subsequent interactions with the member in the Fortuna System.
Contacts the member at regular intervals based on the assigned case management level to determine current status, identify any issues or member concerns, educate the member about their condition and assist in the coordination of care/services.
Maintains case files and provides assistance with appropriate documentation.
Participates in scheduled case management rounds with the UHC Medical Director.
May include the management of complex case management cases and/or prenatal cases.
Prenatal case management may also include the newborn enrollment process in conjunction with the Enrollment Department.
Works in collaboration with the Disease Management Case Managers to identify members who would benefit from the Disease Management program.
Follows accepted standards of practices through the use of evidence based medical principals, standards and practices.
Promotes effective and efficient utilization of clinical resources.
Other duties as assigned.
Requirements and Preferences:
Excellent phone/communication skills - able to convey key concepts clearly and succinctly.
Active listening skills – ability to give full attention and focus on conversations details and data.
Customer Service –strong desire to service hospitalized members, providers and vendors.
Ability to prioritize and follow up on assigned cases.
The UHC Quality Management Program is an organization wide, integrated program designed to improve the quality of care and service for UHC...