Performs care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Essential duties may include, but are not limited to: Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cares for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups. This position may require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and will function as preceptor for new care management staff. Also actively participates in department audit activities and performs other related duties as required. Performs other duties as assigned.
Requires bachelors degree or higher in a health related field and licensure as a health professional, or certification as a care manager, or unrestricted RN licensure in applicable states and 5 years clinical experience. Bachelors degree in nursing, certification in appropriate product/service, clinical or care management experience appropriate to demands desired. Requires knowledge of health insurance/benefits. Requires knowledge of care management assessment technique, provider community, and community resources. Three years experience in home health/discharge planning preferred. Must have strong oral, written and interpersonal communication skills, PC skills to include word processing, spreadsheet, and database applications, organizational and problem-solving skills, and decision-making skills. Must be able to be licenses in multiple states on a timely basis. The following are level distinctions that are not required for posting. This level manages the most complex cases, may participate in department audit activities, serve as preceptor for new associates and participate in or lead projects with cross-functional teams
Once an offer is accepted, all external applicants are subject to a background investigation
and if appropriate, drug testing. Offers of employment shall be contingent upon
passing both the background investigation and drug testing (if required).
associate referral process on WorkNet. Official guidelines for the associate referral
- Current WellPoint associates: All referrals must be submitted through the formal
program can be found in My HR.
American Imaging Management - 2 years ago
We recently changed our name from WellPoint to Anthem, Inc., the name people know us by best. As our companies continue to take a more...