Perform duties related to the day-to-day operations of the High Risk Case Management functions to include working with members identified as high risk to identify needs and goals to achieve empowerment and improved quality of life. Assess members’ current functional level and, in collaboration with the member, develop and monitor the Case Management Treatment Plan, monitor quality of care; assisting with discharge planning, participating in special clinical projects and communicate with departmental and plan administrative staff to facilitate daily operations of the High Risk Case Management functions. Collaborate with both medical and behavioral providers to ensure optimal care for members.
Thorough knowledge of a specialized or technical field such as clinical nursing, case and/or utilization management involving knowledge plus the application of basic theory. Master’s degree in behavioral health and an unrestricted license as a LCSW, LMFT or LPC, or a PhD, PsyD or RN with experience in psychiatric health care settings. Knowledge of utilization review procedures, and familiarity with mental health community resources. 3-5 years of case and/or utilization management experience.
Licenses/Certifications: Unrestricted license as a LCSW, LMFT, PhD, licensed Psychologist or RN
- Work telephonically with patients identified as high risk to identify needs, set goals and implement action steps towards achieving goals. Empower patients to help them improve their quality of life.
- Comply with established referral, pre-certification and authorization policies, procedures and processes by related Medical Management staff.
- Participate in on-going communication between case management staff, utilization management staff, health plan partners and contracted providers.
- Assist with the implementation of policies and procedures regarding case management and utilization management functions.
- Maintain compliance with federal and state regulations and contractual agreements.
- Coordinate case management functions with other departmental functions as assigned.
- Monitor the effectiveness of existing procedures and outreach/intervention efforts.
- Conduct appropriate knowledge/education and interventions for members defined to be at risk.
- Monitor data to address trends or potential quality improvement opportunities including provider issues, service gaps, member needs.
- Maintain HIPAA compliance.
Centene Corporation - 20 months ago
Centene is sensitive to the needs of individuals and families enrolled in government-assisted health programs. The company provides managed...