Reports To: Manager, Health Management Programs
Purpose: To facilitate the accurate administration of benefits, maximize optimal appropriate utilization related to medical necessity, and place of service to foster high quality care in cost effective environment.
1. Communicates and evaluates medical management strategies including potential for alternatives with multidisciplinary team (including member/family and provider/physician organization). Coordinates activities of multidisciplinary team involving providers and family members.
2. Performs prospective case management to reduce/avoid emergency room and hospital utilization.
3. Works as a member of the Disease Management multidisciplinary team in the development and implementation of the program.
4. Enters and maintains critical data in system. Manages databases to assure accurate and timely reporting. Works collaboratively with physician organization, in the analysis and dissemination of utilization/case management information.
5. Maintains current state of the art working knowledge of his/her nursing specialty, CCI products & benefits, and related computer programs through continuing education, community resources and publications.
6. Actively participated in new provider orientations, and ongoing provider and member education programs.
TECHNICAL KNOWLEDGE, EXPERIENCE AND SKILL REQUIREMENTS:
1. RN License in Connecticut.
2. Bachelor's Degree in nursing required or an equivalent combination of education and experience.
3. Minimum of 4 years of clinical experience.
4. Minimum of 1 year experience in an HMO setting preferred.
5. Strong oral and written communication skills.
6. Computer literacy on Windows products.
7. Presentation, organizational and negotiation skills.
1. Member and Customer Focus: Recognizes that members and customers (internal & external) are the driving force behind every business activity. Continuously makes an effort to exceed the expectations of members and customers.
2. Quality Orientation: Assumes responsibility for providing the highest level of quality to members and customers.
3. Innovation: The ability to see opportunities for change, to capitalize on them and implement them when appropriate for the benefit of ConnectiCare.
4. Communication: The ability to communicate with clarity both orally and in writing.
5. Teamwork: Demonstrates enthusiasm for the mission of ConnectiCare and inspires the same in others.
6. Results Orientation: The ability to break a complex problem down into its component parts and arrive at the appropriate solution in a timely fashion.
7. Change Mastery: Embraces change.
8. Learning Orientation: Assumes responsibility for personal and professional development.
ConnectiCare - 2 years ago
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ConnectiCare is one of the largest HMOs in Connecticut. In 1979 a group of doctors at Hartford Hospital planted the seeds for what would...