This position is responsible for case management (excluding Behavioral Health) initiating a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs, utilizing plan benefits and community resources. The incumbent will utilize communications and available resources to promote quality and cost effective outcomes.
Nature & Scope
The incumbent's charge is to work with referrals from multiple sources to identify appropriate candidates for case management.
• Utilization Management Vendor
• Trigger Diagnoses
• Disease management programs
• Medical Records
• Medical Audit and Review
Marketing Groups Agencies
• Customer Service
• Health Assessment
The incumbent will facilitate formation of 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 Medical Affairs Manager and Medical Directors for the
implementation of medical management programs across all lines of business.
Minimum Job Requirements
1. Texas Registered Nurse license that is in good standing with clinical
practice experience or clinical experience with BSN or Master's Degree.
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. Experience in case management, home health, critical care, medical/surgical, social work, discharge planning or concurrent review.
4. Marketing experience preferred.
5. Prefer supervisor/management experience.
6. Above average interpersonal skills
Testing: CRM Navigation (Customer Relationship Management) - evaluates computer comprehension, computer navigation, and basic comcputer literacy
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. Facilitate appropriate cost effective and cost containment measures.
2. Adhere to Enterprise Case Management Standards.
3. Practice case management within the scope of licensure.
4. Cooperate and work effectively with all regional and departmental staff to facilitate
services to members and providers of care.
5. Remain current with medical and surgical procedures, products, services, and drugs by
attending RCM Meeting, conferences, home studies, and inservices.
6. Monitor effective claims adjudication based on guidelines for contracted services.
7. Identify appropriate alternate care settings.
8. Participate in quality improvement program.
9. Provide education to provider community, groups and hospitals to facilitate
understanding of case management program.
10. Prompt case findings which are essential to assure timely transfer to alternative care.
11. Work closely with hospital discharge planners and home care providers to establish plan,
identify the alternate setting, including necessary equipment is in place and operational,
and providers being available upon discharge.
12. Contact member and physician explaining case management services, ensuring that all
parties involved agree to voluntary case management services.
13. Monitor contracted and case by case negotiations with providers for quality of care
issues, cost effectiveness, accessibility, levels of services provided utilizing JCACHO
providers when possible.
14. Must be able to maintain a minimum patient caseload of at any given time and
15. Work referrals daily.
16. Work with marketing department to educate groups or individuals about case
17. Maintain continuous, effective communication between regions regarding case
management of multi-regional cases.
18. Maintain continuous, effective communication with internal and external vendors.
19. Assist Marketing/Underwriting with research.
Arkansas Blue Cross and Blue Shield - 11 months ago