Responsible for the assessment, planning, implementation, coordination, monitoring, and evaluation of case management services for members identified with complex medical, surgical, mental health and/or chemical dependency requiring social service support services. Interacts with Medical Directors, UM department staff, various other Molina staff and providers to deliver cost effective, quality of care services to Molina members, in accordance with Molina policies, procedures and processes. Adheres to the Company/department’s confidentiality and HIPAA compliance programs. Adheres to the company’s/department’s fraud and abuse prevention/detection policies and programs .
Duties and Responsibilities
Provides various care coordination activities in collaboration with the member’s primary care physician, specialist physician, UM staff, disease management staff, medical case manager, mental health professionals, public agencies, and other providers as required. Documents all findings, contacts and interventions. Coordinates necessary services with participating ancillary service providers and public agencies as appropriate. Maintains regular communication with state agencies, healthcare individuals and support systems to promote efficient and well-coordinated quality care .
Develops case management recommendations consistent with the preferences of member and family and incorporating care goals based on identified needs and required services with a significant focus on psychosocial concerns. Determines appropriate frequency and type of contacts to meet care plan goals based on assessment. Case management includes ongoing assessment of health needs, individualized care plans, implementation, monitoring and evaluation of outcomes. Arranges for health care services within the scope of available benefits using sound medical and financial management. Communicates plan to various professionals involved in the member’s care.
Assists members with the completion of documents necessary for application for various community and state programs including Children’s Special Health Care Services (CSHCS).
Maintains active case load of a minimum of 50 cases by actively seeking appropriate cases through established triggers including but not limited to collaboration with other UM department staff, review of inpatient census, team meetings for census review.
Provides leadership and direction to ensure appropriate follow-through, reporting and documentation. Assists other department team members when social service needs are identified .
Establishes and maintains professional rapport with providers, members, public agencies, and other case managers involved in the members care .
Knowledge, Skills and Abilities
Must have experience in a clinical setting with a working knowledge of a variety of medical concerns as well as mental health and chemical dependency treatment .
Must have excellent oral and written communications skill to ensure accurate exchange of information and to build rapport that will ensure the trust, confidence and cooperation of others in a work situation .
Must have the skills to learn and adapt to company policies and procedures as they relate to hospital authorization/denials, physician review, appeals, etc.
Must have the ability to successfully apply established guidelines and regulation to individual and specific situations.
Must have excellent organization skills to establishing and maintaining a variety of records necessary to provide complete information and documentation for relevant and appropriate medical determination.
Must have excellent interpersonal skills
Must be PC literate (MicroSoft Office Suite)
Excellent verbal and written communication skill s
Ability to abide by Molina’s policies
Maintain regular attendance based on agreed-upon schedule
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA )
Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
List other duties which are of secondary importance and marginal to the position’s purpose.
Other duties as assigned .
Master’s Degree in Social Work
3-plus years social work experience
Experience in discharge planning, home health or transitional care .
Preferred: Knowledge of applicable state, federal and third party regulations and standards (Champus, Labor and Industry, SSI Program).
Knowledge of social support systems and resources.
Certified to practice in specific State
Certified Social Worker
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions . Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
To all current Molina employees if you are interested in applying for this position please fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online. Be sure to let us know you are a current employee by selecting “Molina Employee (current) in the source section of the online application.
Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Navigating the murky waters of federal health care plans is no easy feat, but Molina Healthcare's mission is to help Medicaid and...