ABOUT US

Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.

Position Summary

Healthcare Delivery is an umbrella term used to communicate a collaborative process between care and case management. It is designed to help enrollees navigate the healthcare system assuring that they move through the continuum with ease to obtain the right provider in the right treatment seating to establish the right diagnosis, care, and treatment plan. The goal is to oversee and ensure the quality of the relevant care is coordinated and delivered in a timely manner, while promoting appropriate utilization management of medical services by reducing costs and using plan resources. It is the goal of medical management that enrollees receive whatever they are entitled to under their benefit plan based on medical necessity. Utilization management, disease management and the other functions assures that the level of care is appropriate to the healthcare need of each enrollee, and repetitive, unnecessary, or inappropriate services are eliminated as part of fraud, waste, and abuse.

The role of Clinical Care Specialist (CCS) duties includes the coordination of care that is being managed by professional providers, planning, and operational intervention of FCC enrollees. The CCS will follow policies/procedures that are consistent with nationally accepted guideline, protocols, using criteria sets, as well as evidence-based medicine in accordance with FCC’s contract with the State of Florida’s Agency for Health Care Administration (AHCA).

The CCS supports comprehensive coordination of medical services including intake, screening and referrals to FCC utilization management and review processes, chronic [disease] management, transitions of care and discharge planning, Healthy Behaviors [prevention], wellness and EPSDT (children) federal prevention programming, while promoting and supporting quality effectiveness of healthcare services.

Essential Functions

1. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
2. Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/ recommendation/ discharge planning along the continuum of care.
3. Makes appropriate referrals to the Medical Director
4. Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
5. Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
6. Identifies members who may benefit from case management programs and facilitates referral.
7. Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
8. Creating and updating personalized specific requests for services to be rendered through the operation of utilization management or prior authorization, concurrent review, transition of care/discharge planning, and disease management, prevention, and wellness interventions for designated enrollees.
9. Collaborating with enrollee’s provider(s) families, friends, and social supports in request of products and services or developing individualized plans for disease management, prevention, and wellness programs.
10. Identifying the need for products and services that are less expensive.
11. Interacting with healthcare providers to facilitate patients' need for products and services for care and treatment as medically necessary, medically reasonable, or medically appropriate.
12. Ensuring enrollee’s treatment requirements are ultimately met.
13. Suggesting alternative treatment plans when enrollee’s services requests do not meet medical necessity criteria.
14. Instructing and educating enrollee on procedures, healthcare provider instructions and referrals.
15. Linking enrollee to social services programs and entitlements such as transportation assistance and translation services.
16. Conducting regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.
17. Maintaining records of case management activities.

Education and Experience

• Active, Unrestricted Florida RN License is required.
• BS or MSN preferred.
• Must have 5 years managed care/health plan experience.
• Must have 5 years clinical practice experience, e.g., hospital setting, alternative care setting, such as home health or ambulatory care.
• Utilization Management experience and/or Transitions of Care and discharge Planning experience and/or Disease Management experience and/or Prevention and Wellness experience preferred.
• Skills: proficiency with MSWord, MS Excel, and MS PowerPoint knowledge required.
• Must be fluent in English both written and verbal.
• Fluency in Spanish or Creole preferred.

Required Skills

• This position is open to Registered Nurses (RN) with active and unrestricted Florida licensed. The candidate must have experience and expertise in Utilization Management, Disease Management and Prevention/Wellness; and a working knowledge or episodes of care/transition of care/discharge planning. CCS represent that portion of medical management clinical staff that assists providers, on behalf of the enrollees, as well as the enrollees overall in their pursuit of FCC plan requirements that are in accordance with FCC contract with AHCA. These include, but are not limited to, prior authorizations, concurrent review when in an acute or sub-acute facility, as well as, keeping the providers involved are up to date with case information and collaborate with enrollees’ families, friends and caretakers that are legally assigned to effectively share information. 
• The CCS shall be responsible to contact and speak directly with enrollees and providers, as well as legal representatives and care givers. As a CCS the candidate will be a link for the enrollee to products, services and treatment interventions, and self-management programs. The job demands a willingness to guide enrollees through the healthcare system and cultivate relationships with healthcare providers. 
• Top candidates for this position will be able to actively multitask in a dynamic environment and have excellent negotiation skills. This position is unlike a case manager or a care coordinator in that it is based on a series of products and services that will require prior authorization, facility admissions that require concurrent review for continued stay and the functional management of four to eight specific disease states as a captive monitoring pursuit. Therefore, the functions of a care manager recognized by FCC do not represent or should be inferred to be interchangeable with a case manager or care coordinator.

EEO STATEMENT 

In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.