This position assists in ensuring that quality, cost-effective care is delivered to members of all product lines of HealthNow NY Inc. The incumbent will assist in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits. This position will also assess, plan, coordinate, implement, monitor, and/or evaluate the options and services to meet an individual's health needs.
Primary Job Duties:
Acting as an advocate and liaison to meet a member's individual health care needs by assessing, planning, implementing, coordinating, monitoring and evaluating options and services. This is accomplished by using communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits. (30%)
Exhibits and applies clinical understanding (in related discipline) of the medical diagnosis (es), case management processes, and psycho-social needs of members and their support system toward the development of an appropriate treatment plan in conjunction with the member's physician(s) and other pertinent allied health professionals (30%)
Works collaboratively and communicates clearly and professionally with physicians, providers, co-workers and other members of the health care team in order to carry out the established plan of care. (10%)
Demonstrates a thorough understanding of and applies the principles/standards of URAC and NCQA, Medical Services initiatives, and Strategic Business Unit goals. (10%)
Identifies areas for potential cost savings, quality improvement and workflow efficiencies. (10%)
Ability to work both as a team member and independently, demonstrating sound problem solving techniques. (10%)
For Behavioral Health positions: Facilitates integration of behavioral health case management into the member's overall medical treatment plan. Educates member about mental or physical illness, abuse, medication, or available community resources.
For Inpatient Clinicians: Facilitates integration of inpatient care coordination and transition of care into the member's overall medical treatment plan; Supports and educates members and families regarding inpatient processes as needed; Communicates and facilitates post acute member needs.
Excellent time management skills
Excellent verbal and written communication skills
Ability to work effectively with minor supervision
Must be able to work in a fast-paced environment with daily work processing deadlines
High energy level and ability to project enthusiasm
Persuasive communication style
Polished, professional image and reputation
Demonstrated customer service orientation
Demonstrated personal accountability
Knowledge of MS Word, Excel, Access, and Internet preferred
Knowledge of case management, managed care, health insurance industry, and the provider community a plus
Bachelors Degree (Nursing)
CCM designation required within 3 years of accepting position. 3 years clinical experience, 1 year of which must be in a hospital setting. Multi-state RN licensure preferred. Associates degree considered with RN and equivalent experience.
No degree specified (N/A)
For Behavioral Health positions: requires Bachelors of Nursing(BSN), Masters of Social Work(MSW), Licensed Clinical Social Worker(LCSW), Licensed Mental Health Counselor(LMHC), or Licensed Marriage and Family Therapist(LMFT). Recent experience in assessing and managing behavioral health and/or medical diagnoses. Multi state RN preferred.
No degree specified (N/A)
For Inpatient Clinicians: Inpatient case management or discharge planning experience desirable.
Must be able to work in an office environment
Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
PPD Skin Test may be required by healthcare facility for onsite facility work
Certified Case Manager
HealthNow New York Inc. - 15 months ago