The Diversion Case Manager is responsible for conducting face-to-face assessment and enrollment interviews with members for the purpose of establishing Plans of Care and intervention plans for the member. The Diversion Case Manager will initiate referrals to network providers adhering with the company’s policies and procedures and oversee service delivery. Upon the enrollment of patient, implement the case management process, acting as a patient advocate seeking and coordinating solutions to patients’ health care needs. They will participate in quality management, working in a process that spans the continuum of care from primary prevention to long-term health maintenance for individuals with certain chronic health conditions or diagnoses and all other duties as assigned.
Skill Requirements and Preferences:
- Under the direct supervision of the Team Leader coordinate the delivery of services to members adhering to the policies and procedures of the various Medicare/Medicaid programs
- Reassess and coordinate ongoing case management
- Follow accepted standards of practices through the use of evidence based medical principles, standards, and practices
- Meets time guideline requirements for care delivery established by the State and related agencies
- Develop and implement the Plan of Care upon completion of the admission assessment and reassessment
- Interface with acute care providers (hospital and SNF) to assist with community discharge plans on patient
- Create cost analysis of referrals
- Knowledge of laws, legal codes, precedents, government regulations, executive orders, agency rules, as they relate to Managed Care, Medicaid and other lines of company business
- Coordination of plan of care with formal and informal care givers
- Maintain ongoing relations with Providers, Regulator and Members
- Conduct one face-to-face visit with each member at least every ninety calendar days from the date of enrollment.
- Case manager must make necessary emergency plans for other shelter arrangements with the participant or representative during the enrollment orientation process and follow up annually.
- Conduct timely annual re-assessments (701B) and monthly member contact documenting accordingly
Educational Requirements and Experience:
- Must have excellent communication skills both verbal and written, and be able to convey articulate ideas up and down the organizational chart
- Must possess strong organizational, time management and interpersonal skills.
- Must possess analytical planning and mapping abilities
- Must be proficient with computer software programs such as Word and Excel and be able to use company email
- Must have access to a reliable transport (motor vehicle), valid driver’s license and proof of insurance
- Must have completed four (4) hours of in-service training annually and the Abuse, Neglect and Exploitation training specifically involving the elderly
- Four hours of in-service training on issues affecting the frail elderly.
- Alzheimer’s disease and related disorders annual continuing educaton training from a qualified individual or entity, focusing on newly developed topics in the field
- Must be qualified in one of the following ways: (a) have a Bachelor’s Degree in Social Work, Sociology, Psychology, Gerontology or related field, (b) be a Registered Nurse, licensed to practice in the state, (c) have a Bachelor’s Degree in an unrelated field and at least two (2) years of geriatric experience, or (d) be a Licensed Practical Nurse (LPN) with four (4) years of geriatric experience
- All case managers must have at least two years of geriatric experience
Universal Health Care - 13 months ago