Provide case management services which promote quality, cost-effective outcomes by helping selected member populations achieve effective utilization of healthcare services. Incorporate the essential functions of professional case management concepts to enhance patients’ quality of life and maximize health plan benefits. These functions include, but are not limited to:
* Coordination and delivery of healthcare services
* Consideration of physical, psychological, and cultural factors
* Assessment of the patient’s specific health plan benefits and additional medical, community, or financial resources available
Collect and assess patient information pertinent to patient’s history, condition, and functional abilities in order to develop a comprehensive, individualized care plan that promotes wellness, appropriate utilization, and cost-effective care and services.
Develop, implement, and coordinate case management action plan for achieving specified patient goals as determined by the case management plan. Coordinate necessary resources to achieve goals and objectives.
Monitor and evaluate appropriateness of case management action plan, assess progress toward meeting goals, and modify the plan to help achieve desired patient outcomes.
Perform concurrent review of patients admitted to hospitals. Maintain telephone contact with the hospital utilization review personnel to assure appropriateness of continued stay and level of care. Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, home health or hospice services.
Manage mental health- and chemical dependency- related cases to assure appropriateness of level of care (inpatient, residential, and outpatient) within contract benefits. Serve as a resource to assist patient and patient’s family in accessing appropriate providers, facilities, and community resources for their behavioral healthcare needs.
Review referral and preauthorization requests for appropriateness of care within contract guidelines. Incorporate knowledge of mortality, morbidity, and established standards of practice associated with surgical procedures, pharmaceuticals, medical and behavioral health diagnoses.
Identify high exposure cases, case management or utilization review issues, pertinent inquiries, problems, and decisions that may require review, and inform the Medical Director. Present and document pertinent information to support recommended action plan.
Identify and negotiate with appropriate vendors to provide services. When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development.
Serve as primary resource to patient and family members for questions and concerns related to the health plan and in navigating through the health systems issues.
Track and manage provider claims related to caseload. Work with Claims Department to assure timely and accurate adjudication of claims.
Review and audit selected provider claims referred by the Claims Department. Determine and advise regarding the appropriateness of reimbursement for services, considering diagnosis, pre-existing conditions, elective treatment, and contract provisions.
Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.
Identify catastrophic or high exposure cases and prepares written summary for monthly Large Case Report.
Assist Medical Director in developing guidelines and procedures for the Health Services Department.
Work with Medical Director to facilitate patient appeals. Prepare case presentations, as directed, for Medical Grievance Review Claims and Utilization Review Committee, Policy and Procedure Review Committee (PPRC), and/or the Membership Rights Panel (MRP).
Act as backup for other Health Services Department staff and functions as needed.
Serve on designated committees, teams, and task groups, as directed.
Work with Medical Director in responding to inquiries or complaints to the Insurance Commission, preparing reports for other review functions, and addressing grievances and appeals.
Assist contracted case management and/or utilization review providers in contract interpretation and to assure appropriate utilization and cost-effective care.
Represent the Heath Services Department, both internally and externally, as requested by Medical Director.
Perform other duties as assigned.
Work Experience: Five years nursing experience with varied medical exposure and experience. Experience in case management, including cases that require rehabilitation, home health, and hospice treatment. Insurance industry experience preferred.
Language skills: Excellent communication and negotiation skills, both verbal and written.
Mathematical Skills: Basic math skills required, including percentages, ratios, graphing, and spreadsheet skills.
Reasoning Ability: Make decisions for care outside contractual benefits that are mutually beneficial and cost-effective for the member/patient and PacificSource.
Education, Certificates, Licenses, Registration: Registered nurse with current Idaho License. Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification) , or equivalent strongly desired and/or willingness to obtain certification within 2 years.
Other Skills and Abilities: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes including ICD-9, DSM-IV, and CPT Codes, health insurance and State of Oregon-mandated benefits. Ability to deal with members/ patients at all levels of care and crisis. Thorough knowledge and understanding of contractual benefits and options available outside contractual benefits. Thorough knowledge of community services, providers, vendors and facilities available to assist members. Thorough knowledge of creating appropriate case management plans. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Accurately interprets contractual benefits. Accurately documents case notes and letters of explanation which may become part of legal records. Maintains current clinical knowledge base and certification. Supports policy and change process, both internal and with providers. Keeps the Medical Director apprised of case management issues. Accountable for understanding the concept of internal and external customers and the importance of courtesy to all. Knowledge of surgical procedures, diagnoses, and appropriate care modalities. Knowledge of health insurance and State of Oregon mandated benefits. Ability to work independently with minimal supervision.
Environment: Works inside in a general office setting with ergonomically configured equipment and some outside service calls, including visits to other health care settings.
Mental / Physical Requirements:
Requires sitting, standing, walking, stooping, and bending according to work tasks. Light lifting and carrying of files and department notebooks. Must be able to read text and numbers and communicate clearly and distinctly using a voice telephone and in person. Handles files, computer keyboard, and writing instruments.
This job description indicates the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
PacificSource is an equal opportunity and affirmative action employer.
PacificSource Health Plans - 13 months ago
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