To participate in the High Risk Intensive Case Management Program (HRCMP), Care Transitions Program (CTP) and/or Home Visiting Nurse Practitioner program. Implement actions necessary to address identified needs of high risk members in consultation with the Intensive Case Management (ICM) Team. Interview members and/or their providers to identify those who require assistance and/or health plan intervention into any of these programs.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Act as a point of contact for members or providers calling to request assistance and information about the HRCMP, CTP or Home Visiting Nurse Practitioner Program.
Care Transitions Program
- Provide assistance to Care Transitions Coach (CTC) to meet member needs
- Schedule and maintain calendar of visits for Care Transitions Coach
- Document all interventions in Case Management data system and maintain data integrity.
Complex Case Management Program
Exception Needs Care Coordination (ENCC)
- Conduct initial interview of members referred for consideration for the Complex Case Management Program.
- Verbal and written case summary presentation to appropriate HRCMP team members.
- Assist members according to identified needs and/or as guided by the HRCMP team. Members may need assistance with: 1) navigating the health care delivery system, 2) gaining access to appropriate community resources, and/or 3) determining ways to improve self care management and satisfaction with qualify of life indicators.
- Take action to address identified needs, including, but not limited to: 1) scheduling provider appointments, 2) arranging for transportation, 3) verifying needed services are provided, 4) healthcare coaching, 5) encouraging motivation to change non-healthy behaviors, 6) locating members, and 7) contributing to and implementing an integrated plan of care under the direction of an ICM team member.
- Support the medical management plan of the member’s primary and specialty providers.
- Collaborate with specialists, community providers and their staff, state workers, business partners, vendors, agencies and other relevant parties.
- Acknowledge member’s right to choose or refuse program participation.
- Assist members to ensure timely access to providers and services.
- Under the direction of the ICM, communicate the member’s unique needs to the provider for consideration in planning treatment.
- Under the direction of the ICM, assist providers with coordination of services and support discharge plan.
- Aid with coordinating community support and social services systems linkage with medical care systems, as deemed necessary and appropriate and as needed, in consultation with the ICM.
Care Coordination to Home Visiting Program
- Coordinate resource utilization based on the members health care benefits.
- Creatively utilize available resources in the most cost effective manner in collaboration with the ICM.
- Act as point of contact within the department for members or providers calling to request assistance and information about the Home Visiting Program.
- Prepares initial referral package.
- Maintain and updates a list of all cases.
- Acts as liaison for communication of HealthPlan utilization.
- Meets face to face on a regular basis to identify and assist Home Visiting provider with care coordination needs.
Customer Service and Confidentiality
- Maintains list of enrollees for programs under HCG responsibility.
- Obtain information as requested by the ICM.
- Forward information requests, as directed by the ICM.
- Maintain care coordination files according to unit protocols.
- Provide other assistance as required by the ICM.
SECONDARY DUTIES AND RESPONSIBILITIES
- Communicate in a professional and respectful manner.
- Maintain confidentiality.
- Respond to inquiries in a timely manner.
- Handle care coordination needs within established timelines and according to unit protocols.
- Provide training to new employees on specific tasks related to their job responsibilities.
- Follow department and organizational policies and procedures.
- Perform other duties and projects as assigned.
Education and Experience
High school diploma required. Two years experience working in a clinic, hospital, or health insurance plan interviewing patients and/or members for health information required; OR any work experience and/or training that would likely provide the ability to perform the essential functions of the position. Preference may be given to those candidates who are a licensed practical nurse, Pharmacy Technician, certified medical assistant or certified nurse’s assistant certificate.
Special Skills, Licenses and Certifications
Ability to use good judgment. Takes personal initiative and uses discretion in performing job responsibilities. Basic knowledge of medical terminology. Basic knowledge of ICD9 and CPT codes. Knowledge of the PHC and Medicare A & B benefit packages. Ability to learn case management role within a health plan setting. Ability to learn effective motivational interviewing, health care teaching and counseling. Ability to learn the Health Plan eligibility categories. Ability to use computer software for word processing, spreadsheets and electronic mail. Ability to attend to detail and to be accurate. Ability to operate multiple computer programs simultaneously. Knowledge of basic concepts of managed care. Ability to work in an environment with diverse individuals and groups. Ability to establish collaborative relationships. Ability to work autonomously within a team setting. Valid California driver’s license with no restrictions and proof of insurance.
Performance Based Competencies
Effective oral and written communications skills. Ability to deal effectively with Medi-Cal and other special needs populations. Ability to work with ethnically and culturally diverse populations. Ability to maintain positive, cooperative relationships with the community, professional groups, public officials and agencies. Ability to manage multiple tasks. Bi-lingual skills in Spanish preferred.
Work Environment And Physical Demands
Standard cubicle workstation with a shared common area. Use of telephone, fax, computer and photocopying machine is required. Requires sitting in front of computer equipment and talking on telephone for major portion of the workday. Must be able to work in a fast paced environment and maintain courtesy and composure when dealing with internal and external customers. Ability to prioritize work load and initiate action to acquire needed information from professionals by phone. Ability to function effectively with frequent interruptions and directions from multiple team members. When necessary, must be able to lift, move or carry objects of varying size weighing up to 35 lbs. Must be able to operate a vehicle used for company business.
All Healthplan employees are expected to:
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the Healthplan’s policies and procedures as they may from time to time be updated.
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, education factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive, or work environment change.
Partnership HealthPlan of California - 12 months ago