This position is responsible for proactive case management for the Medicare Advantage product , initiating a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an older individual's health needs/education, utilizing plan benefits and community resources. The incumbent will utilize communications and available resources to promote quality for most effective outcomes, member self-management education (may include primary prevention, behavior modification programs and compliance), etc. Special emphasis will be placed on High Risk Members. The incumbent will actively participate in Quality Improvement Programs.
Nature & Scope
The incumbent’s charge is to work with referrals from multiple sources to identify appropriate candidates for case management.
Referral sources: *Health Risk Assessment
* Hospital Utilization Management
*Disease Management Programs
*Medical Audit and Review
The incumbent will facilitate and work with health care teams to include patients, families/caregivers, physicians, and all other ancillary providers and must have the ability to communicate at all levels, often in a highly charged, emotional environment.
This position works closely with the EMM staff as well as Regional Quality Program Managers, Case Managers and Medical Directors for the implementation of medical management programs for the Medicare Advantage product.
Minimum Job Requirements
1. Arkansas Registered Nurse license and 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. Geriatric nursing preferred and geriatric case management experience required.
4. A bachelors (or higher) degree in a health related filed preferred.
5. Experience in case management, home health, critical care, medical/surgical, social work, discharge planning or concurrent review preferred.
6. Prefer supervisor/management experience.
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)
1. Receives referrals from automated Health Risk Assessments or notification of admission as primary identifier for case management services.
2. Performs Eldercare Assessment with member for family to identify further needs, establishes a case management plan, and provides interventions to meet goals.
3. Documents assessment, plan, goals, and interventions in case management system and maintains case documentation according to URAC Standard between 95-100% based on a random sampling of charts on a monthly basis.
4. Works collaboratively with hospital discharge planners, home care providers, and other community resources to establish member case management plans and identify appropriate settings to facilitate cost effective and holistic case management measures and prevent inpatient re-admissions whenever appropriate for level of care.
5. Maintains appropriate follow-up with cases, re-evaluating plan and changing interventions as appropriate.
6. Researches available alternate care resources and community resources and assesses financial implication of accessing resources for the member.
7. Assesses home environment either directly or through other resources such as family members or home health.
8. Adheres to Enterprise Case Management Standards and Professional Geriatric Care Managers Standards of Practice.
9. Practices case management within the scope of licensure.
10. Coordinates member engagement with all regional and departmental staff to facilitate services to members and providers of care.
11. Remains current with medical and surgical procedures, products, services, and drugs by attending RCM Meetings, conferences, home studies, and in-services.
12. Actively participates in Quality Improvement program.
13. Provides education to provider community, groups and hospitals to facilitate understanding of case management program.
14. Provides prompt case finding which is essential to assure timely transfer to alternative care.
15. Contact member and physician explaining case management services, ensuring that all parties involved agree to voluntary case management services.
16. Monitors contracted and case by case negotiations with providers for quality of care issues, cost effectiveness, accessibility, and level of service provided, utilizing contracted providers when possible.
17. Maintains a patient caseload per Policy and Procedure.
18. Works referrals from all referral sources daily.
19. Works with marketing department to educate groups or individuals about proactive case management.
20. Maintains continuous, effective communication between regions regarding case management of multi-regional cases.
21. Maintains continuous, effective communication with internal and external vendors and community resources.
22. Promotes healthy aging through education and activity.
23. Screens for depression and refers to primary care practitioner, as needed.
24. Work with behavioral health case managers in co-case management of complicated medical/behavioral health issues.
25. Facilitates healthcare needs being provided in the least restrictive setting.
26. Assists members in planning for physician visits to insure that all issues or questions are addressed.
27. Works with member and pharmacy director to insure annual review of medications. Uses CCA to screen for potential drug interactions and refers to primary care practitioner as needed.
Goals that Case Managers strive to achieve include:
• Assist the member and family to achieve optimum functioning
• Coordinate the delivery of physician ordered services as well as community services, decrease fragmentation, and assist with appropriate use of resources
• Enhance the quality of life for the individual and family
• Support the physician/patient relationship and plan of care
• Improve and facilitate interdisciplinary communication and planning
• Help to strengthen the member/family unit to cope with catastrophic and/or chronic illness
• Maximize the health of the member by increasing health education that promotes wellness in spite of chronic illness
• Proactively identify problems and needs and coordinate services that provide appropriate high-quality care to meet the individual needs of the member/family
• Emphasize prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies *Involve the member/family as a part of the health care team
• Prevent inappropriate inpatient admissions
Skills, Knowledge, and Abilities
1. Above average interpersonal skills, with special emphasis on communicating with the geriatric member and caregivers.
2. Problem solving skills.
3. Organize workflow and distribution.
4. Make decisions based on facts and assume responsibilities for these decisions.
5. Broad knowledge of current trends in health care and knowledge of medical economics.
7. Broad knowledge of statewide resources available to the geriatric member/family.
8. Work closely with physicians, provider community and members.
9. Communicate effectively both orally and in writing with all levels within the region, the provider community, regulatory agencies and the general public.
10. Establish goals and plan effective methods to achieve those goals.
11. Medical record review skills.
12. Assess the medical/psychosocial/home environment.
13. Participate in inter-regional/corporate standard/protocol development and Best Practice identification.
Arkansas Blue Cross and Blue Shield - 7 months ago