Case Manager - RN Required - Waipahu, HI
WellCare - Honolulu, HI

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1203634

About WellCare: WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Florida, WellCare offers a variety of health plans for families, children, and the aged, blind, and disabled, as well as prescription drug plans. For more information about WellCare, please visit the Company's website at www.wellcare.com.

Our History: Founded in 1985 with three associates, WellCare grew to more than 800 associates and 467,000 members in Florida, New York and Connecticut by 2002. In 2004, the company acquired Harmony to enter the Midwest and became publicly traded. By 2006, WellCare served 2.2 million members as it became a national prescription drug plan provider and the largest Medicaid plan in Georgia. WellCare expanded its services when it began offering Medicaid managed care plans in Ohio and Missouri in 2007, and Medicare managed care plans in Texas and New Jersey in 2008. Additional growth followed when the company was chosen to serve Hawaii's Medicaid program for the aged, blind or disabled in 2009, and in 2011 when it was selected to serve Kentucky's Medicaid program. Today, WellCare has more than 3,900 associates and approximately 2.4 million members nationwide.

EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.

Description

The Case Manager coordinates the care and services of selected member populations across the continuum of illness. Promotes effective utilization and monitors health care resources. Assumes a leadership role within the interdisciplinary team to achieve optimal clinical and resource outcomes. Works with the Supervisor / Manager of Case Management to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Member.

Essential Functions:
In conjunction with the PCP and member, completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the member's need for alternative services. Assess short-term and long-term needs and establishes case management objectives.

Manages 80 to 120 active cases based on case intensity and acuity.

Interacts continuously with member, family, physician(s) and other providers utilizing clinical knowledge and expertise to determine medical history and current status. Assess the options for care including use of benefits and community resources to update the care plan.

Acts as liaison and member advocate between the member/family, physician and facilities/agencies.

Maintains accurate records of case management activities in the EMMA System using clinical guidelines.

Coordinates community resources with emphasis on medical, behavioral and social services. Applies case management standards and maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.

Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.

Schedules or facilitates scheduling appointments and follow-up services

Requests consultation and diagnostic reports from network specialists.

Contacts members to remind them about upcoming appointments and/or missed appointments

Participates in monthly chart audits.

Performs special projects as assigned.

Qualifications

Education/Experience:
A Bachelor's Degree in Health Services. BSN preferred

2-4 years clinical acute care experience, preferably in home health, physicians office or public health.

At least 1-3 years current case management experience

Licenses/Certifications:
Current State RN licensure. CCM preferred

Special Skills (e.g. 2

nd

language):
Bilingual skills a plus

Assists in evaluating process improvements

Ability to work independently, handle multiple assignments and prioritize workload

Demonstrates high level time management and priority setting

Communicates effectively in person and by phone

Advanced ability as a licensed professional to communicate on any level required to meet the demands of the position.

Ability to create, review and interpret treatment plans

Demonstrates negotiation skills

Computer Skills

:

Intermediate knowledge and skills of MS Office including Excel, Word and Outlook Express

Other Position Requirements:
Knowledge of Sidewinder and Diamond system sufficient to perform review and data entry preferred

Ability to learn company approved software including CRMS database, EMMA and Diamond computer system and other industry software in order to perform job duties

Primary Location

HI-Oahu-Honolulu

Travel

No

Is a relocation package available?

No

WellCare - 19 months ago - save job - block
About this company
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WellCare knows that to get well, all you need is a little care. WellCare Health Plans provides managed-care administrative services to...