This position reports to and collaborates with the Quality Program Manager (or designee). This position is responsible for initiating a collaborative process with the member. This process assesses plans, implements, advocates, coordinates, monitors and evaluates the options and services required to meet an individual's health needs across all levels of the healthcare continuum. The incumbent will utilize effective communication skills and available resources to promote quality effective outcomes, member self-management, preventative care and health education.
Nature & Scope
1. Actively participate in Quality Improvement initiatives/projects
Overall responsibility to document all aspects of members care related to quality reporting/initiatives/projects
Become actively involved in the quality improvement process, including but not limited to regional and departmental clinical quality improvement initiatives
2 Maintain appropriate documentation of case management roles, functions and activities as evidenced by review of clinical documentation to meet criteria as outlined within the CMSA Standards of Practice.
Conducting a comprehensive assessment of the each members health and psychosocial needs, including health literacy status and deficits, and develops a case management plan collaboratively with the member and family or caregiver.
Planning with the member, family or caregiver, the primary care physician/
provider, other health care providers, the payer, and the community, to maximize
health care responses, quality, and cost effective outcomes
Facilitating communication and coordination between members of the healthcare team, involving the member and/or caregiver in the decision-making process in order to minimize fragmentation in the services
Educating the member the family or caregiver, and members of the health care
delivery team about treatment options, community resources, insurance benefits,
psychosocial concerns, case management, etc., so that timely and informed decisions can be made
Empowering the member to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes.
Encouraging the appropriate use of health care services and strive to improve quality of care and maintain cost effectiveness on a case-by-case basis.
Assisting the member in the safe transitioning of care to the next most appropriate level, including medication reconciliation and member education on importance of following medication regimen
Ability to promote member self-advocacy and self-determination
Advocating for both the member and the payer to facilitate positive outcomes for
the client, the health care team, and the payer.
Promoting member awareness related to preventative care and health education resources facilitating access/referrals as necessary. Be aware of and document community resources, these should be submitted to the QPM for incorporation into organizational resources.
Meet or exceed goal number of cases per year as demonstrated through documentation through case load reporting
Maintain documentation on a daily basis for onsite/community activities (onsite facilities, onsite member visits, physician office visits, community facilities visits, etc.), as verified by CRR documentation scores
Maintain home office for telecommuting in compliance with guidelines provided by the organization upon set up (an annual attestation in POWER to attest that the office integrity is being maintained according to standard)
3 Maintain appropriate documentation in support of accreditation activities
Participate in educational sessions (on-line/meetings) related to accreditation initiatives, professional growth and organizational goals
Maintain clinical records within documentation limits set by medical management to achieve/maintain accreditation/re-accreditation
Participate in corrective action plans as necessary
Maintain current licensure and certification in accordance with all applicable state, regulatory, policy and procedures and certification requirements, for each state of licensure
Maintain compliance with Enterprise Medical Management Policies and Procedures
4. Maintain positive relationships with both internal and external customers
Cooperate and work effectively with all regional and departmental staff to facilitate services to members and providers of care.
Participate in inter-regional/corporate standard/protocol development and best practice identification.
Work collaboratively with hospital discharge planners, home care providers, and community resources to establish a CM plan and identify the appropriate care setting individualized for the member
Monitor contracted and case by case negotiations with providers for quality of care issues, cost effectiveness, accessibility, level of services provided utilizing contracted providers when possible.
Facilitate effective communication between the member and other members of the healthcare delivery team to assist the member in achieving their individual healthcare goals
Maintain ethical relationships with all internal and external customers
5. Maintain confidentiality, in accordance with the corporate Patient Specific Medical Information (PSMI) policy, of all medical and proprietary information.
Minimum Job Requirements
1. A Registered Nurse licensed in Arkansas or compact state, in good standing, with clinical practice experience.
2. CCM Certification required. If certification not obtained prior to employment, must be eligible to sit for exam by the second year of employment.
3. A bachelors (or higher) degree in a health related field preferred
4. Experience in case management, home health, critical care, medical/surgical, social work, discharge planning or concurrent review preferred.
5. Prefer supervisor/management experience in clinical, home health or case management setting.
6. Travel required.
7. Must have valid Arkansas driver's license with goo ddriving record. Incumbent must meet requirements of company policy
This position is identified as level three (3). This position must ensure the security
and confidentiality of records and information to prevent substantial harm, embarrassment,
inconvenience, or unfairness to any individual on whom information is maintained.
The integrity of information must be maintained as outlined in the company Administrative
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented
or detected on a timely basis by employees in the normal course of business. This
position must adhere to the segregation of duties guidelines in the Administrative
PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
Skills, Knowledge, and Abilities
1. Above average interpersonal skills
2. Above average problem solving skills
3. Ability to organize workflow and set priorities
4. Ability to make decisions based on facts and assumes responsibilities for these decisions.
5. Broad knowledge of current trends in health care and knowledge of medical economics
6. Above average math skills
7. Possess basic computer skills
8. Knowledge of statewide resources both medical and community based
9. Ability to work closely and effectively with physicians, provider community and members
10. Ability to communicate effectively and succinctly both orally and in writing with all levels of customers within the region, the provider community, regulatory agencies and the general public
11. Ability to establish collaborative goals with the member and plan effective methods to assist the member in achieving those goals
12. Ability to, telephonically or onsite, assess member status, perform assessment necessary to achieve positive healthcare outcomes and achieve member specific health care goals
Arkansas Blue Cross and Blue Shield - 4 months ago
In 2012, Arkansas Blue Cross was named one of central Arkansas’ “Top Work Places” by the Arkansas Democrat-Gazette and...